Quality Account
2012/13
To improve continuously the quality of all aspects of our services
East and North Hertfordshire NHS Trust | Quality Account 2012/13
Contents
Part 1:
3
1a
Statement on quality from the Chief Executive
3
1b
Statement by the Board of Directors
4
1c
Trust vision and strategic plan
4
1d
How we monitor quality
6
1e
A year in the life…..
8
Part 2:
9
2a
9
Priorities for improvement:
•
•
2b
Priorities for 2013/14
A review of 2012/13 priorities
Statements of assurance from the Board
9
14
32
Part 3:
47
3a
47
A review of quality performance in 2012/13:
•
•
•
Patient safety
Clinical effectiveness
Patient experiences
48
51
53
3b
Our staff
60
3c
Our changing hospitals
64
3d
Performance against national requirements
67
3e
Statements from stakeholders
68
3f
Statement from auditors
73
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and
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!
n too!!
surgeo
hoices,
(NHS C
013)
April 2
Overviews given in the pale
yellow boxes provide a brief
summary of the information within
that section, or further
explanation of a complex matter.
If members of the public would
like to provide feedback on this
Quality Account or suggest items
for inclusion in next years report
please email
qualityaccount.enh-tr@nhs.net
or contact the Board Secretary on
01438 314333.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
2
Part 1
1a Statement on quality from the Chief Executive
2012/13 has been an exciting year for the Trust
as initiatives to improve services through
redesign and centralisation take shape. We are
seeing the benefits of such work including some
of the best outcomes nationally for patients who
have had a fractured hip. The centralised
maternity unit is in its second year; and the
feedback from women is that they are having a
much better experience than before in a unit
that costs £1 million a year less to run.
This demonstrates our commitment – to be
amongst the best – whilst ensuring that our
services are efficient and financially robust. Our
Quality Governance and Risk Management
Strategy drives this ambition, underpinned by
our objectives and values.
It has also been a year of great challenge – to
meet the financial constraints imposed upon all
NHS organisations whilst improving services.
We continue to work with Clinicenta, the
company who owns the Lister Surgicentre, to
address concerns about the Ophthalmology
service. We are committed to ensuring our
patients receive safe and effective care when
they are treated by partner organisations.
We have comprehensive systems for monitoring
our services and have delivered all of the national
standards; being particularly proud of being
amongst the best nationally for infection
prevention and control.
Of course, none of this would be possible without
the dedication, understanding and hard work of
our staff and our volunteers. I would like to take
this opportunity to thank them. My thanks also go
to our members and stakeholders for their
assistance in guiding the Trusts development.
We are delighted to have received full approval
from the Department of Health to undertake the
planned changes so that the Lister Hospital
becomes the main centre for inpatient and
emergency care across east and north
Hertfordshire, as well as parts of Bedfordshire.
This Quality Account provides just a snapshot of
all that has been achieved by our staff, for our
patients. To the best of my knowledge the
information in this document is accurate.
The Trust is registered without conditions by the
Care Quality Commission (CQC). The CQC
published one inspection report this year
regarding a range of standards including the
assessment and monitoring of the quality of
services. The CQC declared the Trust compliant
with all standards assessed.
We have an open culture where we learn from
mistakes and are honest with staff, patients and
the public
Nick Carver
Chief Executive
A note on the Francis Inquiry
The Executive Team have reviewed all recommendations of the Francis Report and discussed these
during a Board development session in March. The Trust is clear that whilst improvements in quality
have been made within the Trust, as detailed within this report, there is no room for complacency.
In a memo to all staff the Chairman and Chief Executive stated:
“The key lessons from the Francis report, however, is that we individually and collectively, whatever our
role within the Trust, must redouble our efforts in striving to become amongst the best in providing the
best possible care for our patients.”
East and North Hertfordshire NHS Trust | Quality Account 2012/13
3
1c Trust vision and strategic plan
Vision
The Trust aspires ‘to be amongst the
best’ performing NHS Trusts in the country.
Objectives
We recognise the importance of providing high
quality care so one of our Trust objectives is:
“to improve continuously the quality
of all aspects of our services.”
East and North Hertfordshire NHS Trust | Quality Account 2012/13
4
Values
Engagement
The Trust underpins its vision through the
delivery of five values. Known as ‘pivot’ we
believe our values summarise the way the Trust
wishes to work. The values are built into the
recruitment and appraisal processes and have
been the focus of a significant staff development
programme during 2012/13.
We want to be accountable to local people and our
local communities. This will further develop from
our Engagement Strategy (2012-14) that seeks to
make the most of our many and complex
relationships with stakeholders. We will engage to
improve patient experience, provide services that
are accessible and responsive, increase public
confidence in the Trust and enhance its reputation.
We are increasing involvement opportunities for
all our stakeholders to put our hospitals back at the
heart of local communities and so create robust and
sustainable governance.
Being open
We are committed to being open with the local
population about our services and the care we
deliver. Board meetings are held in public and
serve to monitor data relating to safety,
effectiveness and patient experiences. The
documents presented at Board meetings, together
with a whole range of Trust data and information,
are published on the Trust website http://
www.enherts-tr.nhs.uk/about-the-trust/boardmeetings
Sometimes we make mistakes. When this happens
we aim to be open and honest with our patients and
their families; to explain what has happened and to
say sorry.
Sustainability
Application for Foundation Trust
status
We remain committed to achieving Foundation
Trust (FT) status – and in particular the principle
of being accountable to the local community and
membership – and continue to work towards
achieving this ambition. In 2012/13 delays
encountered from receiving the approval of the
final phase of the Trust reconfiguration
programme and from changes to the
financial surplus delivered, meant our
application was unable to progress to the
final stages. We will agree a revised FT
timeline with the new Trust Development
Authority which also enables us to focus
on the final stages of our reconfiguration
programme which will achieve better
clinical outcomes and experience for
patients.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
In December the Lister Hospital’s combined heat
and power plant was switched on. The hospital’s
electricity, heating and cooling needs for the
foreseeable future have been secured. The
immediate benefits include the reduction of energy
bills by an estimated £0.65 million per year; a fall in
carbon emissions by nearly 20% (significantly more
than the Department of Health’s target) and a
consequent reduction under the new carbon tax
that came into effect from 2012. Such a project
symbolises the Trust’s plans for sustainability.
5
1d How we monitor quality
A strategy for quality
The Quality Governance and Risk Management
Strategy (2012), which is aligned with the Trusts
objectives and annual plan, outlines how quality
is incorporated into the everyday business of
the organisation. This strategy is supported by
the Patient Safety Strategy, the Patients and
Carers Experience Strategy and the Improving
Patient Outcomes plans.
Driving quality through measuring
and reporting
In order to understand how well, or not, we are
doing we monitor numerous ‘indicators’ – these
are particular aspects of a service that can be
measured. Examples are the number of patients
on a waiting list or the percentage of time an
operating theatre is in use. It is important to
measure such indicators as it demonstrates
how efficient the Trust is in using its resources;
and how effective it is in achieving the best
outcomes.
Indicators may be measured daily, monthly,
quarterly etc. The data can be compared with
previous data to measure changes. Some data
can be compared with national data so we can
either share our good practices with other
Trusts or learn from other organisations that are
doing better than us.
Information is collected and presented in a
number of different ways allowing:
•
•
•
at a glance monitoring, such as our Board
floodlight report
trends analysis of specific indicators
comparisons with other organisations
(known as benchmarking)
Driving quality through
accountability
The Trust has a well established accountability
framework within its committee and management
structures to support quality .
Committee structure
The Risk and Quality Committee (RAQC) has
delegated responsibility for oversight of all
aspects of quality. The committee holds to
account the executive directors, on relevant
aspects of their portfolio.
Trust Board
Risk and Quality
Committee
Clinical Governance
Strategy Committee
Patient Experience
Committee
Patient Safety
Committee
The main sub-committees for monitoring quality
are the Clinical Governance Strategy Committee
(Chaired by the Medical Director), the Patient
Experience Committee (chaired by the Director of
Nursing and Patient Experience), the Patient
Safety Committee (Chaired by the Associate
Medical Director for Patient Safety) . These each
receive scheduled reports from departments,
committees or individuals tasked with quality
improvement, for monitoring and assurance
purposes. A process of escalation enables any
concerns or significant achievements to be
shared with the parent committee.
Data is presented to a range of committees for
monitoring; and to relevant departments for their
review and improvement where necessary.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
6
Management structure
Each Clinical Division and Specialty is led by
dedicated medical, nursing and management
teams. Together they are responsible for
quality within their own areas and are held
accountable for this through the organisation
hierarchy structure. There are similar
accountability arrangements within the nonclinical divisions such as human resources.
Performance reviews
Performance reviews are held every two
months, or more frequently if required. The
executive directors meet formally with
Divisional leads and their supporting staff to
review all aspects of quality – to praise
developments and the achievement of required
standards; and to challenge and monitor any
areas where improvement is required.
Rolling half days (RHD)
Each month (except August) all nonemergency activity is suspended for half a day
to allow a significant proportion of team
members to meet and review their practices.
This dedicated time offers an opportunity for
review and planning.
Results of audits are discussed; indicators are
Reviewed; feedback is considered and new
departmental or national initiatives are
introduced.
A document entitled ‘learning points’ is
prepared each month and circulated as part of
the RHD information pack. This summarises
key points or themes that have arisen in the
previous month that clinical teams should be
aware of. Examples of such learning points
includes findings from claims or a specific
recommendation following an investigation.
In January 2013 sets of specialty indicator sets
were developed and introduced as part of the
RHD process so that specialties have available
to them specific data relating to their practices.
This helps them to identify where
improvements may be required as well as
confirming where things are going well.
ith
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East and North Hertfordshire NHS Trust | Quality Account 2012/13
Driving quality through listening to
what you tell us
There are many ways that the views of patients
and the public are heard:
•
•
•
•
•
•
Surveys – electronic surveys on the wards,
postal surveys, national surveys
Letters of thanks
Patient Advice and Liaison Service (PALS)
enquiries and complaints
Through consultation work on service
planning
NHS Choices
Patient and carers focus groups
All of this feedback and information is reviewed
carefully and used to make improvements where
indicated. Detailed information regarding patient
feedback is given in section 3a.
first
s amazing a
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it.
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has been exce
ful”
all very grate
13)
s, February 20
(NHS Choice
“My me
dicatio
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(Anon,
postal s
urvey,
Oct 201
2)
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(Oct 201
7
1e A year in the life….
397 rtment
,
4
2
1
epa
Pharmacy Team
Continuous Improvement
Award winner
D
ency ances
g
r
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Em attend
5639
babies born
14,9
149,485
oper 01
ation
s
first out-patient
appointments
50,36
emerg 0
e
admis ncy
sions
Her Majesty the Queen
opens the Diamond Jubilee
Maternity Unit
Improving experiences
for patients
The new
Emergency Department at
Lister gets underway
31,807 s
an
CT sc
Recognising our
volunteers
East and North Hertfordshire NHS Trust | Quality Account 2012/13
8
Part 2
2a Priorities for improvement
Overview
This section outlines two things: - a look forward to what we aim to achieve in 2013/14 and a look
back in 2012/13 describing progress in achieving our priorities.
The look forward - during 2013/14 we will continue to focus on the same priorities as in 2012/13
although have identified additional ways in which we will measure improvements. This section
highlights what improvements will be measured and how they will be monitored.
The look back - during 2012/13 we looked at safety for older people, improving clinical outcomes, staff
development and improving patient experiences. The results of how successful we were at delivering
these priorities are detailed in this section.
Looking forward - priorities for 2013/14
In order to seek views about priorities for 2013/14 the following actions were taken:
•
•
•
•
•
•
•
•
Flyers were issued during the Trust Annual General Meeting to invite suggestions to the dedicated
email account qualityaccount.enh-tr@nhs.uk
Existing priorities and indicators were reviewed to ensure they were relevant. This formed part of
the debate during the consultation stages
Relevant committees were asked for their comments and ideas:
Patient Safety Committee for safety priorities
•
•
Patient Experience Committee for patient experience priorities
•
Clinical Governance Strategy Committee for priorities about clinical outcomes together
with views on safety and experiences
External stakeholders who are members of the Involvement Committee were asked their views
The Health Scrutiny Committee and the Local Involvement Network were consulted
Regional and national documentation was reviewed to identify likely initiatives
The Trusts ‘improvement aims’ as highlighted in the Annual Plan were aligned with the quality ac
count priorities to ensure there is a common focus
The results were presented to the Risk and Quality Committee for final approval
The four priorities identified for improvement during 2012/13 will remain the same in 2013/14, although
priority 1 will be extended to improve safety in all patient groups.
Priority
2012/13
2013/14
1
Improving safety for older people
Improving safety
2
Improving clinical outcomes
Improving clinical outcomes
3
Staff development / engagement
Staff development / engagement
4
Improving patient experiences
Improving patient experiences
The priorities for 2013/14 and how we aim to achieve them, through the use of indicators, are shown on
pages 10-13.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
9
Priority 1 – Improving safety
No
Indicator
Why this is
important
How this will be
monitored
Where this will be Links with other
monitored and
quality
Lead Director
initiatives
1.1 Reduce
number of
in-patient falls
resulting in
serious harm
Since April 2012
there have been 13
serious harm
incidents and 1 death
as a result of a fall.
Falls may cause
delays in discharge,
may precipitate
surgery and have a
significant emotional
impact upon the
patient and their
family
Analysis of incident
numbers and
grades
Bi-monthly report
to the Risk and
Quality Committee
1.2 Reduce
number of
preventable
hospital
acquired
pressure
ulcers
The Trust exceeded
the 2012/13 plans to
reduce the number of
avoidable grade 2-4
pressure ulcers, and
numbers month by
month are continuing
to fall. We will
endeavour to meet
our plan that no
patient suffers an
avoidable hospital
acquired pressure
ulcer whilst in our
care
1.3 Introduce
regular
nutrition audits
on the wards
Good nutrition helps
to prevent
deterioration and
promote recovery;
consequently
shortening length of
stay
Nursing
ambitions
Outcomes
Root cause analysis Monthly ‘Floodlight’ Framework
of all incidents
report to the Board Domain 5
leading to harm, and
the sharing of
learning
Lead:
Director of Nursing
and Patient
Experience
Analysis of incident
numbers and
grades
Bi-monthly report
to the Risk and
Quality Committee
Nursing
ambitions
Outcomes
Root cause analysis Monthly ‘Floodlight’ Framework
report to the Board Domain 5
of all incidents
leading to harm, and
the sharing of
learning
Lead:
Director of Nursing
and patient
Experience
Analysis of audits as Bi-monthly report
part of the ‘ward
to the Risk and
audit tool’
Quality Committee
Nursing
ambitions
Performance
reviews as part of
ward audit pack
Lead:
Director of Nursing
and Patient
Experience
Aiming High Award
Pirton Ward, June 2012
The award was given for teamwork which resulted in a
significant reduction in the number of falls.
The key changes have included keeping the patients
most at risk of falling together in a single bay, and
improving communication between team members to try
to ensure that the bay area has a member of staff
present at all times.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
10
Priority 2 – Improving clinical outcomes
No
Indicator
2.1 Stroke: meet
all Trust aims
regarding
stroke care
Why this is
important
How this will be
monitored
Where this will be Links with other
monitored and
quality
Lead Director
initiatives
The Trust, as part of
the local health
economy, has
struggled to deliver
the regional health
targets. The Trust
continues to work
with community
partners to improve
the care for people
who have had a
stroke
Review of transient
ischaemic attack
access targets
Monthly ‘Floodlight’
report (and
exception reporting
where necessary)
to the Board
Admission within 4
hours of arrival at
the emergency
Department
Scanning within 60
minutes of arrival
90% of stay on
stroke unit
2.2 Further reduce Whilst the Trust has
Analysis of:
hospital
seen improvements
mortality
in mortality rates over • Hospital
Standardised
the last few years the
Mortality Rate
aim is to be amongst
(HSMR)
the best performing
Trusts. Continued
focus is required to
• Summary
further improve our
Hospital
position
Mortality Indicator (SHMI)
•
SHMI data
adjusted for
palliative care
Focused review of
mortality on nine
key pathways
2.3 Reduce
emergency
admissions for
acute
conditions not
usually
requiring
admissions
Caring for people at
home is better for
them than being in
hospital. It is also
more financially
viable and ensures
hospital beds are
available for those
who need them. The
Trust wishes to work
with community
partners to ensure
that care is delivered
in the most
appropriate place
thus reducing such
admissions by 10%
Quarterly CQUIN*
monitoring of key
milestones
Rollout of AMBER
project (see page
24)
Monitoring of
consultant staff
cover at weekends
Nursing
ambitions
Outcomes
Framework
Domain 1
Bi-monthly
performance
review within the
Medical Division
Lead:
Director of
Operations
Monthly ‘Floodlight’
report and
exception report
where necessary)
to the Board
Bi-monthly report
to the Risk and
Quality Committee
(via Medical
Director report)
Outcomes
Framework
Domain 1
Annual Plan
(Improvement
Priority 1)
Quarterly
monitoring reviews
with the Clinical
Commissioning
Group
Lead:
Medical Director
Monthly ‘Floodlight’
report and
exception report
where necessary)
to the Board
Twice monthly
review by the
Transforming
In-patient
Management
Programme Board
Outcomes
Framework Domain 3
Annual Plan
(Improvement
Priority 2)
CQUIN 5.1
Comparison against
baseline data
Lead:
(baseline to be
Director of
undertaken)
Operations
* CQUIN - commissioning for quality and innovation (see page 37)
East and North Hertfordshire NHS Trust | Quality Account 2012/13
11
Priority 2 – Improving clinical outcomes (cont.)
No
Indicator
Why this is
important
2.4 Improve
Implementation of
post-operative enhanced recovery
outcomes
programmes ensure
patients go home
sooner and with
fewer complications.
This has been seen
in hip fracture surgery
and needs to be
implemented within
other clinical
specialties to improve
patient experience
and Trust efficiency
How this will be
monitored
Where this will be Links with other
monitored and
quality
Lead Director
initiatives
Implementation of
the enhanced
recovery
programme
schedule
Twice monthly
report to the
Transforming
In-patient
Management
Programme Board
Revise Emergency
Surgery pathway
Annual Plan
(Improvement
Priority 3)
Bi-monthly
performance
review within the
Surgery Division
Lead:
Director of
Operations
Priority 3 – Staff development / engagement
No
Indicator
Why this is
important
How this will be
monitored
3.1 Improve staff
survey score
for job
satisfaction
The Trust
recognises that good
patient care is linked
with having happy
staff. These three
indicators are strong
3.3 Improve staff
proxy measures
survey score
representing staff
for
recommending perception
Trust as a
place to work /
receive
treatment
3.2 Improve staff
survey score
for team
working
Analysis of annual
staff survey results
Analysis of local staff
surveys (method to
be revised during
2013/14)
Where this will
be monitored
and Lead
Director
Monthly
‘Floodlight’ report
(and exception
report where
necessary) to the
Board
Links with other
quality
initiatives
Outcomes
Framework
Domain 4
Lead:
Director of
Workforce and
Organisational
Development
Aiming High Award
July 2012 – Histology team
The team at the QEII has faced challenges
following an external review around document
control and internal audit. Following some
exceptional team work, they have focused on
these areas, resolved the issues and adopted
working practices designed to ensure that the
highest standards are maintained.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
12
Priority 4 – Further improve patient experiences
No
Indicator
Why this is
important
How this will be
monitored
Where this will be Links with other
monitored and
quality
Lead Director
initiatives
4.1
Improve
experiences of
patients with
learning
disabilities,
and their
carers
This indicator
combines the desire
to improve
experience for carers
as per Patient and
Carer Experience
Strategy; and for
people with learning
disabilities as per
Learning Disabilities
action plan
Number of referrals
to the Learning
Disability Team
Learning
Disabilities Action
Plan
Question 16 of
carers survey –
rating of good or
very good for level
of support provided
Annual Plan
Lead:
Director of Nursing (Improvement
and Patient
Priority 5)
Experience
Develop net
promoter type
question
(suitable for
children and
young people)
for paediatrics
by June 2013
and
incorporate
into paediatric
surveys from
that date
The existing net
promoter score does
not include
paediatrics and the
recent national
paediatric outpatient
survey indicated
improvements were
required
Improve
patient
experience for
patients with
diabetes
(using DipSat
survey)
A focus upon
diabetes care is
planned for 2013/14
with a range of
outcomes being
measured. Measuring
patient satisfaction
will contribute to the
analysis of how
effective this work
has been
4.2
4.3
Surveys:
Bi-monthly Patient
Experience
Committee as part
• Using Meridian
on Bluebell Ward of net promoter
feedback
• Paper surveys
Bi-monthly report
within the
to the Risk and
emergency
Quality Committee
department,
(via
Director of
neonatal unit and
Nursing
report)
community care
Outcomes
Framework
Domain 2
Outcomes
Framework
Domain 4
Annual Plan
(Improvement
Priority 5)
Lead:
Director of Nursing
and Patient
Experience
Analysis of patient
survey (to be
agreed)
Monitoring of
number of patients
with insulin pump
access for type 1
diabetes
Scheduled Risk
and Quality
Committee and
Board report
Lead:
Director of
Operations
Outcomes
Framework
Domain 4
Annual Plan
(Improvement
Priorities 4&5)
Aiming High Award
July 2012 - Endoscopy
The endoscopy units at QEII and Lister have
looked at patient feedback and improved communication, patient admission and waiting
times as a result.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
13
Retirement of indicators
Some of the indicators used to monitor the 2012/13 priorities will be retired from this section of the report
because they are part of ordinary business and are no longer appropriate as improvement priorities.
Assurance about future reporting arrangements is given below.
Indicator
Awareness and diagnosis of dementia
Improve access to surgery within 36 hours
(fractured hip)
Maintain mortality improvements following a
hip fracture
Increase the number of patients who would
recommend the Trust [Friends & family test /
Net promoter score]
Plan for 2013/14
To be incorporated into the CQUIN measure
To feature in part 3 - clinical effectiveness
section
To feature in part 3 - clinical effectiveness
section
To feature in part 3 - patient experiences section
Further reduce sickness rate
Due to consistently high scores this indicator will
be monitored by the division as part of ongoing
performance monitoring
To feature in part 3 - clinical effectiveness
section
To feature in part 3 - staff section
Further increase the appraisal rate
Increase use of central venous access devices
(tubes into large veins) for delivery of chemotherapy
To feature in part 3 - staff section
This indicator will form part of everyday practice
with overall monitoring at the divisional level of the
length of stay
Sustain improvements in experiences after
birth as measured by patient surveys
Liverpool Care Pathway
Looking back - a review of 2012/13 priorities
Overview
The following section shows that we have:
•
•
•
•
•
•
•
•
reduced the number of falls and harm from falls
reduced the number of pressure ulcers
met all dementia aims
improved ways to keep our patients nourished and hydrated
maintained outcomes for surgery and continued to reduce mortality
ensured patient choice for patients being cared for on the Liverpool Care Pathway
maintained low sickness levels
received encouraging feedback from patients and carers about their experience but recognise
there is more to be achieved.
Also shown is that we need to work closely with our community partners to improve the care offered
to people who have had a stroke; and we need to improve the appraisal process at divisional level.
Key:
The key is based upon the thresholds set by the Board, at the beginning of each year, which are
used to monitor performance throughout the year.
Achieved
~
Under achieved (defined mid-range as given on the Trust floodlight)
Not achieved
East and North Hertfordshire NHS Trust | Quality Account 2012/13
14
Priority 1 – improving safety for older people
Aim 1.1 – falls
09/10
Reduce number of in-patient falls
resulting in serious harm for all age
groups (2012/13 definition)
Reduce number of in-patient falls
resulting in serious harm ie. fractures
from falls
10/11
11/12
12/13
Plan for
12/13
N/A
N/A
N/A
14
<24
15
24
29
21
N/A
A national change in the definition of severe harm
from falls during 2012 means that two sets of data
is required to describe the 2012/13 outcome
figures and careful interpretation is required.
From 2012/13 the definition of what is categorised
as serious harm includes death, severe or
moderate harm from head injury; eye injury;
dislocated hips and lacerations as a result of a
fall. The definition does not include moderate
fractures eg. the wrist. In total there have been 14
injuries according to this definition. The Trust will
continue to endeavour to reduce this further.
The Trust planned to reduce the number of
in-patient falls by 25% against the 2011/12 figure.
In 2012/13 there were 1224 in-patient falls,
exceeding the plan and demonstrating a 25.8%
reduction compared with 2011/12.
In 2011/12 there were 29 reported fractures from
falls. Using this same methodology in 2012/13
there have been 21 fractures resulting from falls
during the year. Graphical representation is
shown below.
Achieved
N/A
Examples of initiatives implemented:
•
•
•
•
•
Continuation of ‘intentional rounding’, at
one to two hourly intervals, where staff
check that patients are comfortable, if
they require assistance with toileting and
have their belongings ie. slippers, glasses
and call bell near to hand
Where possible, endeavour to have a
member of staff in a bay at all times
Risk assessment of all patients on
admission to ward areas
Ward based training availability for all staff
groups
An Acute Falls Prevention Practitioner has
been appointed to work with the lead
ortho-geriatricians, the fractured hip nurse,
the new A&E clinical navigators and the
community falls liaison service to develop
care pathways which aim to reduce hospital admissions from falls in over 65 year
olds. The practitioner also works with
Trust clinical staff to reduce in-patient
falls and set up referral pathways at
hospital discharge into community
services for patients with falls risk.
Severe and m oderate harm fractures from falls
6
5
4
2011/ 12
3
2012/ 13
2
1
0
Apr
May
Jun
Jul
Aug Sept
Oct
Nov
Dec
Jan
Feb
Mar
M ont h
97.7% of falls incidents in year were
categorised as ‘none’ or ‘low harm’.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
m my
proved fro
im
d
a
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s
Thing
ted with
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15
Aim 1.2 – pressure ulcers
10/11
Reduce number of preventable hospital acquired
pressure ulcers by 25% 2012 (grade 2+)
The ambitious aim to achieve zero pressure
ulcers from the end of December has not been
achieved. The Trust will continue its endeavours
towards minimising all avoidable pressure
ulcers.
12/13
Plan for
12/13
335
323
113
120
-
-
13
Zero from
Jan 2013
Reduce the number of preventable hospital
acquired pressure ulcers to zero by, and from, end
December 2012
There has been a 48% reduction in the number of
grade 2-4 hospital acquired pressure ulcers in
2012/13 compared with 2011/12.
11/12
•
•
•
Achieved
The Acute Surgical Assessment Unit is
trialling the use of a silicone tape to see if
this will help to reduce pressure and
friction caused my external devices such
as oxygen masks and tubing
100 foam mattresses have been ordered
to replace damaged mattresses
Pressure ulcer free days, by ward, are
now captured and circulated to all ward
managers each month. Celebration
events have been introduced for
those wards that have extended
periods of time without any hospital
acquired pressure ulcers.
Since measuring pressure
ulcer free days 9 wards have
achieved more than one
pressure ulcer free year.
Examples of initiatives implemented:
•
•
•
•
•
The Trust participated in a Strategic Health
Authority collaborative to roll-out a method
of identifying and acting quickly on any
evidence of skin redness
Production of a film for staff, patients and
visitors to ‘stop the pressure’, available via
the Trust website
Prospective validation of all reported
pressure ulcers
Monthly walk rounds to all the wards by the
Deputy Director of Nursing and Tissue
Viability team to promote the importance of
pressure ulcer prevention and to support
staff
Targeted support to clinical areas which
have recurring pressure ulcers to help them
to review their practice in relation to pressure ulcer prevention
East and North Hertfordshire NHS Trust | Quality Account 2012/13
Pressure ulcers
Commonly known as bed sores, people develop
these ulcers as a result of continued pressure
on the skin – mainly on their bottom or heels.
There are four grades of ulcer:
1 – skin is red but unbroken
2 – shallow skin break (like a graze)
3 – deep skin break involving all layers of skin
4 – very deep skin break with damage affecting
muscle and/or bone
People with fragile skin or who have restricted
movement are most at risk of developing them if
the pressure is not relieved through turning,
movement or protection.
16
Aims 1.3 & 1.4 – dementia care
12/13
Screen emergency admissions aged 75+ using the awareness
question to identify dementia
Assess patients identified as having dementia
Variable per
quarter as per
CQUIN
schedule
Plan for
12/13
Achieved
>=90%
>=90%
The aims for dementia care for 2012/13 were
threefold:
•
•
•
Screening emergency admissions to
identify the number of patients with
dementia, some of whom may not realise
they have it, in order to plan best care
accordingly
Assessment of all patients identified from
the screening
Referral of patients assessed as ‘positive’
or ‘inconclusive’ to the GP for follow-up
Nursing staff
not trained
in helping pa
tients with
dementia, w
as
discharged ba
ck to
nursing hom
e in a sorry
state.
Anon, Postal
Survey
Apr 2012
The Trust met all of these aims.
The Older Persons Strategy 2012-15 outlines
the intentions to develop a Frailty/Dementia
care pathway with a rapid assessment interface
and discharge (RAID) service. The RAID
Service became operational in May 2013.
Part of the strategy is to recruit a Dementia
Nurse Specialist. This is underway. The postholder will review patients and support staff and
carers in managing patients with dementia; and
work with community colleagues to assist in
managing complex discharges. A service
review aims to eliminate multiple moves for
older people with dementia for non-clinical
reasons.
The Trust has educated 150 dementia
champions and over 700 staff have received
dementia awareness training.
The Trust reviewed the results of the National
Audit of Dementia in February and produced
an action plan where gaps were identified.
The Trust is compliant in the following areas:
•
•
•
•
•
•
Identification of patients with dementia
upon discharge
Trust involvement with local patient
forums
Social worker availability
Multi-disciplinary assessments
Appropriate protocols for management of
patients with dementia
Liaison with psychiatric teams
Further action is required in the following
areas:
•
•
•
The production of a dementia care
pathway
Providing notice of discharge to carers or
family members
Involvement of carers or family
Oversight of the audit action plan will be
overseen by the Dementia Implementation
Strategy Group.
Staff continue to implement initiatives introduced
in the previous year.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
17
Aim 1.5 – nutrition and hydration
Plan for
12/13
Improve nutrition & hydration
as shown in summary report
Achieved
Produce
report
Written by Gail Franklin...
Nutrition and hydration are essential to health and
well being. They provide a vital contribution for
people recovering from illness and for those at
risk of malnutrition. Malnutrition affects 25% of
adult patients admitted to hospital and can affect
people of all ages including children. Recent
national audits have shown the elderly is at
particular risk of developing malnutrition and
becoming dehydrated in hospitals.
Good nutrition and hydration can help patients by
improving their ability to heal wounds, fight
infections, maintain muscle function for good
mobility and prevent pressure ulcers. This will
shorten their hospital stay and help patients to
recover quicker from their hospital admission.
Various national nutrition initiatives have been
implemented in UK hospitals to improve nutrition
and hydration. These have been introduced within
our Trust and include:
•
•
•
A cup measurement
picture tool assists
accurate recording
of fluid intake
Nutritional screening - malnutrition is often
unrecognised, but with the use of effective
screening, malnourished patients are
identified and treated appropriately. A
validated nutrition screening tool
“Malnutrition Universal Screening
Tool” (MUST) is used for adults, and for
children the “Screening Tool for the
Assessment of Malnutrition in
Paediatrics” (STAMP) is used
Protected mealtimes were designed to allow
patients to eat their meals without disruption
and enable staff to focus on providing
assistance to those patients unable to eat
independently or require assistance with
eating and drinking. Protected mealtimes
have been introduced
The red tray and jug initiatives were initiated
to highlight patients who may need
assistance with eating and drinking or
longer time finishing their meal.
From April 2013 we will introduce regular
nutrition audits on the ward as part of the
“ward audit tool”
East and North Hertfordshire NHS Trust | Quality Account 2012/13
In addition to the introduction of national
initiatives we have:
•
•
•
•
•
Introduced a feeding assistant role (ward
volunteers) to help and encourage
patients at meal times, especially older,
frail patients who may require assistance
to eat and drink
Introduced a Nutrition Care Policy. This
will be rolled out to wards as part of a
“Nutrition bundle” which includes a
patient information leaflet and a revised
and improved Food Record Chart
Developed a rolling programme of
nutrition education and training for
registered nurses for the Identification
and Management of Malnutrition
Introduced nutrition and hydration as part
of the clinical support worker induction
programme to raise awareness of
malnutrition and poor hydration
Revised the Hydration and Fluid balance
Policy
Patients who find it
difficult to reach for,
or use, a cup can
easily drink from
‘The Hydrant’
A patient fluid intake
chart lets patients record
how many drinks they
are taking
18
“Celebration of Excellence”
Improving Safety and Outcomes award winner
Gail Franklin (right), renal lead specialist, nutrition and
dietetics was nominated because of her enthusiasm and
determination which has led the profile of nutrition across the
Trust. With the support of the voluntary services teams, she has
worked to introduce a service which supports the feeding of
vulnerable patients and helps drive our understanding of the
importance of nutrition and hydration.
Priority 2 – improving clinical outcomes
Aims 2.1 & 2.2 – stroke
11/12
12/13
Plan for
12/13
Increase access to TIA (transient ischaemic attack) services
53.3%
>60%
Admission to stroke unit within 4 hours of arrival
47.4%
90%
39.2%
41.9%
20%
83.75%
79.4%
80%
N/A
Comply
Comply
CT Scan within 60 minutes of arrival
90% time in dedicated stroke unit
Improve stroke performance (training and assessment)
The TIA service is provided Monday to Friday at
the Trust with an agreed weekend service at the
Luton and Dunstable Hospital. Access to the
service has been hindered due to cases of
inadequate communication within and outside the
Trust; inappropriate referrals and lack of weekend capacity to deal with the demand. Actions to
address this include:
•
•
•
•
Instigation of daily meetings to review
performance and emerging problems
GP liaison manager has re-communicated
the referral pathway to GPs
Development of an escalation process for
when demand outweighs capacity
Recruitment of a third stroke consultant
Admission to the stroke unit, within four hours of
arrival in the emergency department, has not met
the planned targets for a number of reasons. A
lack of intermediate care beds in the community
means that patients stay longer on the stroke
unit, thus preventing new admissions.
Additionally poor communication between the
emergency and stroke teams has at times
resulted in delays in progressing patient care.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
Achieved
~
Actions to address this include:
•
•
•
Consultant and nurse stroke champions
have been identified within the emergency
department. These members of staff attend
the stroke review meetings and promote
communication between teams
Communication to ensure that patients sent
in by GPs go straight to the Lister Hospital
and not the QEII Hospital which does not
offer full stroke services
Patients due for discharge from the stroke
unit are identified the day before so they can
be discharged early thus releasing beds for
new admissions
The Trust is meeting the target of patients
receiving a brain scan within 60 minutes of arrival:
and all CQUIN aims have been met.
The Trust has not achieved its aim regarding
patients spending over 90% of their admission
time in a stroke bed (although the Trusts amber
threshold is relevant for performance from 6979.99%). Given high demand it is sometimes
necessary for patients to be on other wards,
although clinical decisions are made to ensure the
most appropriate places are prioritised for those
with greatest need.
19
Aims 2.3 & 2.4 – surgery
12/13
Plan for
12/13
Improve emergency access to surgery within 36 hours (%)
92%
>90%
Maintain mortality improvements following a hip fracture
82.8
Below 100
Achieved
*
*rolling 12 month figure sourced from Dr Foster, based against 2011/12, data
The Trust has initiated a programme to improve
trauma and emergency access to theatres.
Progress is monitored as part of the
Transforming Inpatient Management Programme
Board. Although the Trust has met its aim there is
a comprehensive action plan to make further
improvements and to aim towards accessing
theatre within 24 hours. This will be achieved
through:
•
Reduction of time spent in the anaesthetic
room by following standard anaesthetic
‘recipes’ and by optimising anaesthetic
teaching lists
Reducing delays between patients by
introducing a progress chaser role’
Review of staffing rotas so there is no
interruption by planned surgery lists
Identifying and resolving bottlenecks
•
•
•
ry clear
ave us ve
g
se
r
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n
“The
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got
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once we
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nd.”
understa
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uary 201
n
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In the autumn of 2011 changes were put in place
to improve the care and treatment of patients who
had suffered a fractured hip.
As a result the mortality rate reduced (improved)
and patients were less likely to die as a result of
that fracture in our Trust compared with the
overall national average.
This standard has been maintained during
2012/13 with mortality currently averaging 82.8
over a rolling 12 month period against a national
average of 100.
ENHT HSMR Trend - Fracture of Neck of Femur
April 2011 to March 2013
(Control limits +/- 3 SD)
Data source: Dr Foster Intelligence
(2011/12 data benchmark)
350.0
300.0
250.0
Relative Risk
ENHT HSMR
200.0
National Average
150.0
The graph
shows the
hip fracture
mortality
trend since
April 2011
against the
national
average.
100.0
50.0
ay
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0.0
East and North Hertfordshire NHS Trust | Quality Account 2012/13
20
The orthopaedics team follow a best practice
pathway of care and record all steps in care
delivery. This pathway is then audited with
results monitored by the orthopaedic team and
overseen by the Patient Safety Committee. Any
fall in service quality is therefore identified and
acted upon early.
Rates of access to theatre within 24 and 36 hours
are reviewed as well as seniority of
operating surgeon and duration of surgery. As a
snapshot, during March 2013:
•
•
•
•
100% of patients were seen by all relevant
medical teams within appropriate
timescales
100% of patients were seen by an
anaesthetist preoperatively
100% of patients were appropriately risk
assessed for falls, blood clots and
pressure ulcers
67.5% of patients received surgery within 24
hours of admission
The National Hip Fracture Database provides
comparative data across the East of England and
nationally.
The ‘bluebook’ indicators are shown which clearly
demonstrate the Trust is performing better than
regional and national averages in all areas with
the exception of length of stay.
ne no
r
e
fw
al,
staf
en t
and
m
The
e
g
ing h
d
jud
n
uc
sta
der very m
n
u
–
y
lt
V er
safe
I fe
.
d
d
n
a
kin
e.
ase
at e ell don urvey,
s
w
tal
Po s
)
,
n
o
012
il 2
(An
r
p
A
Nurses at the QEII were
fantastic, I was seen
quickly and given pain
relief immediately.
(Anon, Postal survey,
April 2012)
is
nk i t
i
h
t
I
r 10
ful fo
t
c
e
p
d
s
crow
di s r e
o
t
f
f
th e
st a
a nd
NHS
y
a
b
o t he
your
alk t
into
t
o
t
are
or
yo u
doct
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k
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l
ents
.
stud
here
y,
not t
urve
tal s
s
o
P
n,
)
(Ano
2012
J u ly
Aiming High Award
Julie Munsden, Mount Vernon cancer Centre,
November 2012
Julie Munson, clinical nurse specialist, received
her award because of the kindness and empathy
she shows to patients and the support she offers
to colleagues. She was the first individual winner
of this award.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
21
Aim 2.5 – mortality
HSMR – what is this?
The hospital standardised mortality ratio (HSMR) is a way of tracking a hospital’s mortality over time. It is
a measure of the number of people who actually die against the number who are expected to die.
Measuring mortality is complex. It is based upon the average mortality for 56 clinical conditions (affecting
over 80% of our patients) which is adjusted to take account of the local population, eg age and illness.
The figure excludes patients that are expected to die who have been referred for palliative (end of life)
care.
An HSMR equal to 100 suggests that there is no difference between a local mortality rate and the
average national rate. A HSMR below 100 means that a Trust is performing better than the average; a
HSMR above 100 indicates a Trust performing worse than average.
12/13
92.7*
Further improve in-hospital mortality rate (HSMR)
Plan for
12/13
Achieved
<100
*rolling 12 month figure sourced from Dr Foster, based against 2011/12, data
The Trust’s Hospital Standardised Mortality Rate
(HSMR) has remained below 100 for all but 2
months since April 2012. For the 12 months to
March 2013 the HSMR is at 92.7. This means that
the Trusts mortality rate is better than the
national average.
The data reported in this report uses 2012/13
Trust data compared with the England average
2011/12 data. Later in the year an adjustment will
be made to all Trust figures for 2012/13 – known
as rebasing – which takes account of all the data
that becomes available by the end of March 2013.
It is at this point that we will know exactly how
we have compared with other Trusts during
2012/13. Early indications suggest that the
Trusts rebased HSMR is likely to be around 97.
The graph below shows the overall Trust
mortality trend since April 2011 against the
national average.
Details of the Summary Hospital Mortality Index
(SHMI), which is an alternative method of
recording mortality, is included in the mandatory
section 2b of this report.
ENHT HSMR Trend
April 2011 to March 2013
(Control limits +/- 3 SD)
Data source: Dr Foster Intelligence
(2011/12 data benchmark)
160.0
140.0
120.0
ENHT HSMR
Relative Risk
100.0
National Average
80.0
60.0
40.0
20.0
0.0
r
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East and North Hertfordshire NHS Trust | Quality Account 2012/13
22
Review of 5 pathways
During the year the Trust has focused efforts to
improve the care and treatment of patients with
five types of illness. This was because data in
2011/12 showed that mortality was higher than
average. The mortality data for each of these condition is given below.
With the exception of respiratory infections, where
the mortality rose in the winter months (December
and January), all are showing a reduction in
mortality for the full year.
2011/12
113.0
2012/3
89.3
108.1
96.7
Respiratory Infections
99.7
101.7
Septicaemia
122.0
89
Urinary Tract Infection
106.1
81.8
Acute Renal Failure
Congestive Heart
Failure
For each of these conditions the way care and
treatment is delivered has been reviewed and
audits undertaken to identify where problems
have occurred. As a result the following actions
have been taken:
•
•
•
•
Guidelines, care pathways and proformas
have been developed or updated which
define exactly how and when care should
be delivered
A patient safety page has been
developed on the Trust intranet where a
comprehensive range of information on
septicaemia can be accessed within two
clicks of the mouse
The Cardiology on-call rota has been
established
Antibiotic guidelines have been review
following results from audits.
Aim 2.6 – Liverpool care pathway
12/13
% of clinically appropriate patients receiving end of life care to be
offered an advance care plan
Total number of clinically appropriate patients who are cared for
on the Liverpool Care Pathway
% of patients identified to be within the last 12 months of life who
complete an Advance Care Plan (ACP)
% of patients within the last 12 months of life who have indicated
a preferred place of death
End of life care is important to the Trust
particularly as approximately 54% of the local
population will die in the Lister or the QEII
hospitals, compared with only 5% who die in a
local hospice. The palliative care team has seen a
growing demand for end of life care with referrals
increasing by 60% between 2009 and 2012.
National Award
Liz Lees, Nursing
Services Manager
Liz was honoured in the
Macmillan Excellence
Awards for her work in
developing a survey to
assess carers
satisfaction with palliative
care provided to patients
in Hertfordshire.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
Variable
per
quarter
as per
CQUIN
schedule
Plan for
12/13
Achieved
>85%
>85%
N/A
>85%
The Liverpool Care Pathway (LCP) is a
prescribed set of steps to ensure the comfort of
a dying patient and their family. It is best
practice to ensure that dying patients are cared
for as prescribed in the pathway.
The Trusts Palliative Care Team has been
recognised locally and nationally for
implementation of quality initiatives relating to
end of life care. These achievements include:
•
•
•
•
•
•
•
7 day service (only 20% of Trusts
nationally offer this)
Multi professional palliative care team
Implementation of LCP and Advanced
Care Plans
AMBER care bundle project (see pg 24)
Delivery of End of Life strategy
Collaborative working with Speciality
areas i.e. renal, ICU
Education initiatives
23
The second National LCP Audit highlighted use of
medication. Practice in the Trust with respect to
use of strong opioids and sedatives were shown to
be well within the range of standard practice. The
third National LCP Audit identified eight key
performance indicators related to organisational
and clinical performance. Our scores were:
Recent national publicity
Recent adverse publicity in the national press
has highlighted incidents of abuse regarding
end of life care. Accusations made by the
media include:
•
•
•
•
Significantly above average for five
indicators: access to specialist support;
continuing education, training and audit;
anticipatory prescribing; communication with
relatives and carers; compliance with
completion of the LCP document
Average for two indicators: privacy and
dignity protocols and access to information
relating to death and dying
Below average for one indicator: ongoing
routine assessment of patient, relatives or
carers (national 76%, our score 74%)
•
•
Use of the LCP as a form of euthanasia,
with deliberate intent to hasten death
Deliberate deprivation of food and fluids
in patients put on the LCP
Use of unnecessary and excessive
sedation
We have examined the use of the LCP in the
Trust through various audits over a number of
years. The results of these and regular
observations on the wards make us confident
that none of the accusations made against the
LCP can be substantiated with respect to
practice within the Trust.
Amber Care Bundle Project
The Trust is very pleased to have been selected to
introduce the AMBER care bundle over the next
12-18 months and appointed an AMBER project
facilitator in January 2013. AMBER stands for:
Assessment
Management
Best practice
Engagement
Recovery uncertain
“Mount Vernon is first
class in all departments,
thank god I had my
treatment there”
(Anon, Postal survey,
April 2012)
Devised at Guys and St Thomas Foundation Trust
it has been found to reduce emergency
readmissions; support earlier discharge and
enable people to die in their place of preference.
Aim 2.7 – venous access devices
Achieved
Increase use of central venous access devices (tubes into large
veins) for delivery of chemotherapy
Until July 2012, the Marie Curie ward was an 18-bedded
5-day ward. Since then, it has changed to become a 12hour day ward with 16 chairs and 5 beds. A new
treatment room has also been built within the ward,
replacing the old one that was located along the
corridor.
The ward treats patients receiving chemotherapy over
more than four hours, as well as those who need
supportive therapies such as blood transfusions.
Between about 20 and 30 patients are benefiting from
the facilities every day.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
24
Priority 3 – staff development / engagement
Aim 3.1 – sickness
11/12
Further reduce the sickness rate
4.7*%
* This figure has been revised from the 2011/12 quality
account to enable comparisons following the introduction of a
different measuring methodology introduced in January 2012.
Whilst the Trust has not achieved the desired aim
in 2012/13 it must be recognised that nationally a
sickness rate of 3.6% is very low. To this end a
sickness rate below 3.5% has been agreed
appropriate for future monitoring in 2013/14.(The ~
rating takes account of the performance
threshold from 3.01-5%).
12/13
3.6%
Plan for
12/13
<3%
Achieved
~
Only three concerns were identified: two
around policy and a further one around the
effectiveness of the scoring system used to
monitor sickness patterns. The latter will be
reviewed to take account of systems used in
other Trusts.
An audit undertaken by external auditors
commissioned by the Trust, published in January
2013, looked at four aspects around sickness
absence management. The results are very
encouraging with effective management of
absence being scored highly.
Aim 3.2 – appraisals
Further increase the appraisal rate
11/12
12/13
69.9%
70.2%
Plan for
12/13
>=90%
Achieved
~
The percentage of staff who have been appraised in the last year has increased compared to the
previous year. The aim of 90% has not been reached although the result sits within the Trusts amber
threshold of 70-89.99%.
The National NHS Staff
Survey 2012, based on
feedback from our staff,
shows that the Trust is:
•
•
average regarding
the number of
appraisals
undertaken
one of the best 20%
of Trusts for having
structured
appraisals.
The graphs also show the
Trust position compared
with 2011 results.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
25
Divisions have agreed plans to improve the
appraisal rate and, together with their divisional
human resources managers, are monitoring
monthly statistics and ensuring relevant staff are
able to attend appraisal training.
An appraisal action plan was developed in
December which includes:
•
•
•
•
Recommending a maximum number of staff
each manager can appraise
Revising the appraisal policy to include
performance assessment process and
criteria linked to incremental pay scales
Improving the monitoring and
implementation of personal development
plans
Ensuring appraisals are completed at an
appropriate time each year linked to the
incremental pay date
Aim 3.3-3.5 – staff survey
10/11
11/12
12/13
Plan
for
12/13
Improve staff survey score for job
satisfaction
3.55
3.49
3.6
3.33
3.58
Improve staff survey score for team
working
3.62
3.63
3.77
3.77
3.72
Improve staff survey score for
recommending the Trust as a place to
work / receive treatment
3.47
3.49
3.62
3.82
3.57
The organisation is undergoing significant change so
the results shown in the staff survey are
encouraging, particularly in comparison to national
figures.
A comprehensive staff development programme,
known as ARC, (see section 3b) is now well
established and “Delivering Excellent Customer
Care” training has begun for all staff.
An “Amongst the Best” newsletter has been
introduced to share achievements and good
practice and managers have been asked to
ensure that all team meetings include a section for
sharing good news.
Previous ARC sessions have included specific
content on the importance and value of ensuring
managers give regular and effective feedback to
staff; and the content of future sessions will be
Achieved
National
average
influenced by what divisions feel to be important,
thus increasing ownership by, and involvement
of, staff.
A number of initiatives to recognise staff
achievements have been introduced. These
include the annual Celebration of Excellence
awards & Aiming High awards. Winners of
these awards are recognised within this report.
From April 2013 the floodlight reports will be
populated with nationally benchmarked results
from the annual NHS staff survey, for closer
scrutiny of staff feedback. An implementation
plan for the Health and Wellbeing Strategy is
being developed and divisional human
resources managers will work with their
management teams to identify reasons for
areas of concern and develop action plans for
improvements.
Aiming High Award
Blue Team, Ward 10, Mount Vernon Cancer
September 2012
The Blue team on ward 10 at Mount Vernon were
nominated for how they work together to make things
better for patients.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
26
Priority 4 – further improve experiences
Aim 4.1 – maternity care
Achieved
Sustain improvements in experiences after birth as measured by patient surveys:
Treated with kindness and understanding by midwives
Involved in decisions about care
Treated with kindness and understanding by doctors
Enough information about own recovery
Historically feedback about postnatal care showed
that improvements were necessary. Following
centralisation of the maternity units the feedback
improved.
Feedback continues to be monitored on a monthly
basis and the graph clearly shows that
improvements continue to be reported.
Future reporting will continue to be monitored by
the maternity team but given the high scores will
be retired from the quality account.
(Maternity, M
arch 2013)
Feedback on post-natal care
100
95
Score
Kindness & understanding
(midwives)
90
Involved in decisions
85
Kindness & understanding
(doctors)
nformation about recovery
80
M
ay
Ju
n
75
Ap
r
was
are
c
r
er e
afte
we w th
“The s too d wi
l ou
b on
e
o
t
fa b u
en w
ne
h
o
l
w
a
b oy
l e ft
nd
ittle
l
r
to a
nd
d
ou
e
d
kly a s
c
i
n ee
u
q
t wa
ged
en i
har
h
c
s
w
i
”.
y
d
ome
entl
i
h
c
i
o
f
ef
to g
time
2)
201
v
o
ty, N
erni
t
a
(M
“The midwives
that
assisted me in
particular wer
e
wonderful, pr
ofessional
and extremel
y
supportive”.
Ju
l
Au
g
Se
p
O
ct
No
v
De
c
Ja
n
Fe
b
M
ar
•
•
•
•
Month
Aiming High Award
Gloucester and Dacre Wards
Gloucester ward (postnatal) and Dacre ward (antenatal) staff
are the first ever winners of the Aiming High award for their
success in combining maternity staff from the QEll and Lister
sites into a single, united team.
Chosen for the exceptional work they have put in to
improving teamwork and – through better communication –
the care they give to mothers and their babies.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
27
Aim 4.2 – recommending the Trust
12/13
Increase the number of patients who would recommend the Trust
“Friends and Family Test”
The ‘friends and family test’ question asks
71.1
Plan for
12/13
Achieved
71
‘How likely are you to recommend our ward /
department to friends and family if they needed similar
care or treatment?’
The NHS Friends and Family Test will change
from April 2013 where all inpatients and patients
discharged from the emergency department to
home or to the admission units aged 16+ must be
given the opportunity to answer the FFT question.
A range of answer options are given from
extremely likely to extremely unlikely. From the
answers given an overall score—known as the net
promoter– is calculated. The maximum score is
100.
Fr3dom Health Solutions have visited the Trust
and confirmed that we are ready to comply with
the FFT guidance from April 2013. The Trust
achieved 100% in the ‘operational’ and ‘readiness’
categories to meet the FFT guidance.
The Trust has maintained a net promoter score in
the upper quartile (>71) in the East of England
region for 9 out of 12 months in 2012-13 and we
were a consistently high responder to the friends
and family test (FFT) question.
The views of patients are collected via electronic
ward feedback machines and via paper surveys.
Net Promoter Score
Patients are asked whether they would
recommend the Trust. The net promoter score
is calculated by subtracting the figure in red
(those who would not recommend the Trust)
from the figure in green (those who are highly
likely to recommend the Trust).
The chart below shows the percentage breakdown of responses by month.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
28
Aim 4.3 – carers feedback
Achieved
Identify and develop action plan in relation to feedback from carers and patients
with learning disability of those aged over 75 years
The carers survey is sent to all patients aged 75+
who have a carer identified on the patient
administration system, and to carers of all patients
with a learning disability.
From the surveys completed to date the results
confirm that both patients and carers are treated
with respect and courtesy. However the results
also indicate that dementia or learning disability
champions do not necessarily make themselves
known to carers (where applicable), or that the
Acute Liaison Learning Disability Nurses is
involved with the patient (where applicable).
The Adult Safeguarding Nurse has investigated
these responses and is able to confirm that, in the
majority of cases, the Learning Disability Liaison
Nurses had been involved in the care of the
patient either during their hospital stay or as a
follow-up after discharge.
The Health Liaison Team and Safeguarding
Vulnerable Adults Lead Nurse have set up a
Learning Disability Working Group. The group
is currently working on the development of
Care Pathways for patients with a Learning
Disability; and the Learning Disability
Admission Policy has recently been reviewed.
The Health Liaison Team have supported the
Trust to develop an Easy Read Discharge
Booklet to compliment existing patient
information.
The Learning Disability Liaison team and the
Trust received positive feedback on
partnership working arrangements following
Community Nursing and Safeguarding Scrutiny
conducted by Hertfordshire County Council.
The Trust has held four carer’s focus group
meetings during the year.
Carer Friendly Hospital
The Trust is participating in the Carer Friendly
Hospital Initiative. Hertfordshire County Council
has provided funding to appoint a Carers Lead for
one year. The Carer Friendly Hospital initiative at
the Lister Hospital commenced in March 2013 to
support carers. It is recognised that improved
carer support can improve clinical outcomes for
the person being cared for. Evidence suggests
that carer breakdown may be a significant factor
in hospital re-admission, emergency department
attendances and delayed discharges from
hospital.
The Learning Disability Liaison team are now
providing monthly statistics of the patients referred
to them by the Trust. Since April 2012 they have
received 134 referrals and made 1493 contacts.
Referrals increased from 6/month (average) to
14.5/month (average) following the
implementation of an alert flag, identifying patients
with carers, on the patient administration system
in July 2012.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
Helping to make a stay more comfortable.
See ‘Kissing it Better’ on page 59.
The standard of care was
very good but it was the
kindness that really helped
to make it a positive
experience.
(Anon, Postal survey, July
2012)
29
Indicator monitoring
The chart below and on page 31 shows the breakdown of data by month, quarter or year.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
30
East and North Hertfordshire NHS Trust | Quality Account 2012/13
31
2b Statement of assurances from the Board
Overview
This section describes how the services provided by the Trust and the information (data) available
about those services have been reviewed.
•
•
•
•
•
Carrying out clinical audits allows us to check that our practice meets best standards
Monitoring research activity shows that we are developing services to further improve outcomes
Meeting quality targets shows that improvements are being made in important areas
Assessments ensure we are managing information correctly and that our data is of a high
standard
Benchmarking our outcomes against national standards allow us to see how well, or not, we are
performing compared with other organisations
The evaluation of such information enables us to take action accordingly.
In this section “East and North Hertfordshire NHS Trust” will be presented as ‘ENHT’. Please note that
in this section we are required to use specific words to describe services and results.
Review of services
During 2012/13, the East and North Hertfordshire
NHS Trust (ENHT) provided and/or subcontracted 27 relevant health services. The ENHT
has reviewed all the data available to them on the
quality of care in 27 of these relevant health
services. The income generated by the relevant
health services reviewed in 2012/13 represents
100% of the total income generated from the
provision of relevant health services by the ENHT
for 2012/13.
Participation in clinical audits
The Trust has an extensive Clinical Audit (CA)
programme. Each year all clinical teams produce
a ‘Forward Plan’ of audits to be undertaken
throughout that year, based on the Trust’s CA
Priority Guidance, which lists all the mandatory
topics that must be addressed. An overview of
the CA plan for the year, summarising all 693
audits, is given in the table below.
Division
Cancer
National &
regional priority
20
Throughout the year the CA Team receives
information from all specialties regarding the
progress made against their individual Clinical
Audit Forward Plans. This is uploaded to the
central CA Database from which reports are run
for monitoring purposes eg at Performance
Reviews and at the Risk and Quality
Committee.
During 2012/13 38 National Clinical Audits and
5 National Confidential Enquiries covered
relevant health services that the ENHT
provides.
During that period, the ENHT participated in 35
(92%) of the National Clinical Audits and all 6
(100%) of the National Confidential Enquiries
which it was eligible to participate in.
1
Departmental
priority
37
Trust priority
Total
58
Clinical Support
10
4
61
75
Medicine
91
33
89
213
Surgery
55
37
126
218
Women’s & Children’s
74
7
39
120
Trust
2
4
3
9
252
86
355
693
TOTAL
East and North Hertfordshire NHS Trust | Quality Account 2012/13
32
The tables below show:
•
•
•
The National Clinical Audits and National Confidential Enquiries that ENHT was eligible to
participate in during 2012/13
The National Clinical Audits and National Confidential Enquiries that ENHT participated in during
2012/13
The National Clinical Audits and National Confidential Enquires that ENHT participated in, and for
which data collection was completed during 2012/13, 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
Relevant national confidential enquiries
Trust Participation
% Cases
submitted
Asthma Deaths
100%
Child Health
100%
Maternal Infant and Perinatal
100%
NCEPOD Subarachnoid Haemorrhage
100%
NCEPOD Alcohol Related Liver Disease
100%
Organisational checklist
completed
NCEPOD Tracheostomy Care
Suicide and Homicide for Mental health
Relevant national audits
Patient study in progress
Not relevant
N/A
Key: IP—In Progress
Trust Participation
% Cases
submitted
Adult Asthma
N/A1
Adult Community Acquired Pneumonia
N/A1
Acute Coronary Syndrome or Acute Myocardial Infarction
IP
Adult Critical Care
IP
Bowel Cancer
IP
Bronchiectasis
N/A1
Cardiac Arrest
100%
Cardiac Arrhythmia
IP
Carotid Interventions
IP
Comparative Audit of Blood Transfusion
Coronary Angioplasty
100%
IP
Dementia
100%
Diabetes (Adult)
100%
Diabetes (Paediatric)
100%
Elective Surgery
IP
1
In common with most other Trusts, the Respiratory specialty agreed not to audit all the British Thoracic Society (BTS) topics
this year but have set up their own 3-year audit programme on the three topics from 2012/13 onwards. Pneumonia audits using
the BTS pneumonia audit proforma were undertaken during 12/13 as part of the CQUIN (see page 28)
East and North Hertfordshire NHS Trust | Quality Account 2012/13
33
Relevant national audits (cont.)
Trust Participation
Emergency Use of Oxygen
% Cases
submitted
100%
Epilepsy 12 (Childhood Epilepsy)
IP
Fever in Children
100%
Fractured Neck of Femur
100%
Head and Neck Oncology
100%
Heart Failure
IP
Hip Fracture Database
100%
Inflammatory Bowel Disease
IP
Lung Cancer
100%
National Joint Registry
IP
Neonatal Intensive and Special Care
100%
Non-invasive Ventilation
100%
Oesophago-gastric Cancer
100%
Paediatric Asthma
100%
Paediatric Pneumonia
100%
Pain Database
0%2
Parkinson’s Disease
100%
Potential Donor
IP
Renal Colic
100%
Renal Registry
IP
Stroke National Audit Programme
IP
Trauma
IP
Vascular Surgery
IP
2
This stage of the project required clinicians to give patients a questionnaire to fill in and return to Dr Foster. The Audit Lead
reports that the relevant documentation was not received in the Trust until near the end of the audit period, which meant that
only a few patients could be included. Whilst these patients were encouraged to complete and return the questionnaire,
unfortunately it would appear that none did so.
National audits not relevant to the Trust
National audits relevant only to Mental Health Trusts:
•
•
•
Prescribing Observatory for Mental Health
Psychological Therapies
Schizophrenia
National audits where services are not provided by
the Trust:
•
•
•
“When
trying
to get a
Inform
ny
ation,
w
a
s repea
told "yo
t
edly
u'll ha
ve to w
Always
ait".
had to
ask for
no effo
update
rt mad
s,
e at al
l
to keep
me info
rmed”
(NHS C
hoices,
2012)
Orthop
aedics,
Dec
Adult Cardiac Surgery
Congenital Heart Disease (Paediatric cardiac
surgery)
Intra-thoracic Transplant
East and North Hertfordshire NHS Trust | Quality Account 2012/13
34
National audits: - the findings
The reports of the following National Clinical
Audits were reviewed by the provider in 2012/13
and the following are just some of the actions that
ENHT intends to take/has taken to improve the
quality of healthcare.
National Neonatal Audit Programme
The National Neonatal Audit Programme results
for the Trust showed some areas requiring
improvement, for which actions have been
planned, or had already being completed in
response to earlier guidance:
•
•
•
•
•
A Business case submitted to the Neonatal
Network for a breast feeding support role
has been successful, and resulted in the
employment of a Neonatal Breast-feeding
coordinator
A Business case submitted for an additional
consultant for the Neonatal Unit, to meet the
requirements for Consultants/clinics for
Bayleys examination and identification of
early intervention, has also been successful
in funding an additional Neonatal
Consultant specialist
The Trust has improved the environmental
temperature and monitoring in the delivery
suite and theatre
Training and re-emphasis on guidelines for
appropriate transport and documentation for
all Neonatal staff has been implemented
A comprehensive induction training on the
SEND data system for the Medical team
has been introduced with subsequent
improvement in documentation
National Hip Fracture Database
The Trust undertook a reconfiguration of its Hip
Fracture service halfway through the audit year,
so 6 months of data precede the new unit and
associated improvements in quality of care.
The Trust estimates that we now achieve 80% of
Best Practice Tariff standards. An action plan is in
place against the audit findings that will enable
the Trust to further improve performance against
the standards, including the development of nerve
blocks during surgery and a trial of new cemented
implants is being undertaken in clinically
appropriate patients.
staff, care planning, appropriate first clinical
assessment and all required
diagnostic services.
An action plan to address shortfalls is now in
place. Actions include the development of a
care pathway and protocols to improve
assessment, investigation, diagnosis and
management of children with epilepsies.
Myocardial Ischaemia National Audit Project
(MINAP)
The Trust opened its new Hertfordshire
Cardiology Centre at the Lister Hospital in
March 2012, and the MINAP audit results show
the Trust’s performance in almost all standards
to be above 90%, and above the overall results
for England.
The audit highlighted a lower score for
admission of nSTEMI (type of heart attack)
patients to a cardiac ward and, although
performance is above or equal to the England
average, action has been taken by the
Cardiology clinical lead to make improvements
to the admission process.
NCEPOD: Time to intervene? Review of
in-hospital cardiac arrest and resuscitation
attempts
Actions taken to date include:
•
A new Resuscitation policy
•
New cardiac arrest forms to record and
audit arrests
•
New ‘Do Not Attempt Cardio-pulmonary
Resuscitation forms
The Trust has a continuous training programme
carried out by the Resuscitation team and the
National Early Warning Score (NEWS) for
observations to ensure early recognition of
deterioration will be launched in the spring
2013.
National Epilepsy 12 Audit
The report for the National Epilepsy 12 audit
showed that the Trust is performing well for its
childrens’ epilepsy specialist services, including
provision of, and referral to, epilepsy specialist
East and North Hertfordshire NHS Trust | Quality Account 2012/13
35
Departmental audits: - the findings
The reports of 169 local clinical audits were
reviewed by the provider in 2012/13 and the
following are just some of the actions that ENHT
intends to take/has taken to improve the quality of
healthcare provided. (Details taken from the
Outcomes Forms/Action Plans that Audit Leads
are required to complete once an audit has been
undertaken and presented.)
Adequacy of In-Patient Note Documentation
(Trauma & Orthopaedics)
During future local induction of new juniors into
the department, and on consultant ward rounds,
extra emphasis will be given to the need to
comply with Trust standards of documentation
and note keeping.
Audit on Missed Critical Drugs QEII
(Pharmacy)
A training programme is to be set up for ward
nurses and pharmacists regarding the completion
and checking of endorsements.
Neurological Assessment in Emergency
Patients Referred to Orthopaedics with Low
Back Pain (Trauma & Orthopaedics)
A standardised neurological assessment
proforma has been introduced together with a
new admission clerking proforma for use in
patients with back pain or suspected cauda
equina, requiring admission. Information about
cauda equina to be included in the new T&O
Junior Doctors’ Handbook.
NICE CG109: Transient Loss of Consciousness in Adults (Emergency Medicine)
A departmental proforma for transient loss of
consciousness is to be produced.
NICE CG130: Hyperglycaemia in Acute Coronary Syndromes (ACS) (Cardiology)
Medical juniors to be educated about the
importance of measuring body mass (BM) and a
BM2 tick box section is to be added to the ACS
proforma.
Booking and Missed Appointments
(Obstetrics)
Current policy to be revised to reflect the new
process for referral and booking. Staff are to be
educated to differentiate between 'transfer' into
trust and a 'booking'.
NICE CG134: Anaphylaxis (Emergency
Medicine)
Training material based on the NICE guidance,
and a flow chart for use in resuscitation on the
management of patients in anaphylaxis, to be
produced. ICE (Pathology system) order set to
have tryptase included plus a pop up to say
needs repeating in 1 – 4 hours.
Compliance with Trusts Blood Transfusion
Policy 2012-13 (Renal Medicine)
Computerised sign-off for all nephrology and
transplant patients having transfusions to be
instituted on Ward 6B. The importance of clinical
observation during transfusion to be reinforced to
all staff.
Omitted or Delayed Administration of Critical
Medicines in ENHT (Pharmacy)
Posters to be designed and put up around the
hospital and ward stock lists reviewed. Critical
drugs list printed out, laminated and stuck on all
ward drug cupboards.
Do Not attempt Resuscitation Documentation
Audit (E&NH) 2012 (Cancer Centre)
A set of brief guidance notes to assist with
completion of the form, and how to reverse
decisions, is to be printed. The possibility of
including this information on the back of the
DNAR forms is to be investigated.
Documentation Audit 2012-2013 (Cancer
Centre)
A new, standardised Ward Admission Proforma
has been produced.
Handover of Care (On-site) (Obstetrics)
The guideline relating to postnatal transfer to be
updated and staff reminded of the procedures to
be followed.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
Provision of Out of Hours Advice at Mount
Vernon Cancer Centre
Calls will be directed to one centralised point of
contact (24hrs a day) manned by a coordinator
trained in the use of UK Oncology Nursing
Society assessment tools.
Time Taken Between Taking Chemotherapy
'Off Hold' and Patient Receiving It.
(Pharmacy)
Outside-supplier delivery times to Pharmacy to
be monitored in line with service level
agreements.
WHO (World Health Organisation) Surgical
Checklist Compliance (Obstetrics)
A specially adapted version of the WHO surgical
checklist has been produced for use in
Maternity.
36
Research and development
Clinical research involves gathering information to
help us understand the best treatments or
procedures for patients. It also enables new
treatments and medications to be developed.
clinical trials nurse to wound care in the healing
process; the importance of mealtimes in hospitals
and patients’ perceptions of pain.
The number of patients receiving relevant health
services provided or sub-contracted by ENHT in
2012/13 that were recruited during that period to
participate in research approved by a research
ethics committee was 1988 according to the latest
figures available.
Number of patients recruited to Portfolio
studies
Trusts first Nursing and Midwifery
research conference
2864
1638
1720
2008/ 9
2009/ 10
2010/ 11
2011
1988
2011/12
2012/ 13
Patient recruitment into the United Kingdom
Clinical Research Network (UKCRN) portfolio
studies has risen and been maintained over
recent years from 1081 patients in 2007/08. ENHT
has been the top recruiting Trust in the Essex and
Hertfordshire Comprehensive Local Research
Network for the last 5 years. 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.
The Trust was involved in conducting 360 clinical
research studies and used national systems to
manage the studies in proportion to risk. The
majority of the studies were established and
managed under national model agreements. In
2012/13 the National Institute for Health Research
(NIHR) supported 105 of these studies through its
research networks. In the last three years 225
publications have resulted from our involvement in
research, helping to improve patient outcomes
and experience across the NHS. Examples of how
our research activity leads to improvements in
patient care are available in the ENHT Annual
Report.
The Trust hosted its first Nursing & Midwifery
research conference in October 2012.
Discussions included everything from the role of a
East and North Hertfordshire NHS Trust | Quality Account 2012/13
Goals agreed with commissioners
A proportion of the ENHT’s income in 2012/1/3
was conditional on achieving quality
improvement and innovation goals agreed
between the ENHT 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.
Further details of the agreed goals for 2012/13
and for the following 12 month period are
available electronically at www.enht-tr.nhs.uk
Commissioning for Quality and Innovation
(CQUIN) is a way of improving quality by
providing a financial incentive. The Trust
receives either a full or part payment depending
upon the results it achieves. The total value of
the CQUIN payment in 2012/13 amounts to
approximately £6.7 million.
The Trust CQUINs are given on page 38
together with their full monetary value and
details of whether or not these quality
improvements were met.
37
CQUIN
Weighting
Full value
(£ 000)
Achieved
1
Percentage of all adult patients who have had a Venousthromboembolism (VTE) risk assessment
5%
336
100%
2
Improving patient experience – annual adult in-patient
survey
5%
336
60%
3a
Improving care of patients with dementia – case finding
3b
Improving care of patients with dementia – risk
assessment
5%
336
100%
3c
Improving care of patients with dementia – referral
4
Use of NHS Safety Thermometer
Improving outcomes for patients with chronic obstructive
pulmonary disease
Improving patient experience – net promoter baseline
score
Improving patient experience – net promoter Board and
commissioner reporting
Improving patient experience – net promoter weekly
reporting
Improving patient experience – net promoter
performance improvement
Reducing hospital mortality
5%
336
100%
10%
672
100%
10%
672
75%
15%
1008
95%
15%
1008
100%
10%
672
100%
10%
672
100%
5%
336
100%
5%
336
100%
100%
6,720
94.75%
5
6a
6b
6c
6d
7
8
9
10
11a
11b
Improving patient experience – responding to feedback
from carers of in-patients with a learning disability or
aged over 75 years
Improving outcomes for patients following a stroke
Making every second count (opportunities for lifestyle
changes)
Improving care of patients on a cancer care pathway –
assessment and care planning
Improving care of patients on a cancer care pathway –
improvement of care within the last 12 months of life
Statements from the Care Quality
Commission
The ENHT is required to register with the Care
Quality Commission (CQC) and its current
registration status is registered with no conditions.
The Care Quality Commission's Quality and Risk
profile (QRP) brings together information about
the Trust and provides an estimate of the risk of
non compliance against each of the 16 essential
standards of quality and safety. ENHT uses the
QRP ratings to support its internal process for
monitoring compliance with the Essential
Standards of Quality and Safety. A Trust wide
summary of compliance is submitted to both the
East and North Hertfordshire NHS Trust | Quality Account 2012/13
Risk and Quality Committee and Trust Board
on a monthly basis. Detailed compliance reports are submitted to the Risk and Quality
Committee on a quarterly basis.
The CQC has not taken enforcement action
against ENHT during 2012/13.
ENHT has participated in special reviews or
investigations by the Care Quality Commission
during 2012/13.
The CQC carried out a routine, unannounced
inspection of the Lister hospital on the 6th and
7th December 2012.
38
The inspection team tested compliance against
5 outcomes:
•
•
•
•
•
met their needs at the Lister hospital and had
been involved, where possible, in decisions about
this. People's health, safety and welfare was
protected when more than one provider was
involved in their care and treatment, or when they
moved between different services. People were
also protected from the risk of abuse because
ENHT had taken reasonable steps to identify the
possibility of abuse and prevent abuse from
happening. People spoken with told CQC that
there were adequate staff in place to meet
people's needs on a day to day basis. ENHT
provided CQC with evidence that showed that
staff at the Trust worked to continuously improve
the quality of all aspects of their services through
the review of progress against organisational
performance priorities and strategies.
Outcome 4 (care and welfare)
Outcome 6 (cooperating with other
providers)
Outcome 7 (safeguarding people who use
services from abuse)
Outcome 13 (staffing)
Outcome 16 (assessing and monitoring the
quality of service provision).
During the two day inspection the inspectors
interviewed key members of staff, visited several
wards where they spoke to clinical staff, patients
and their families and also reviewed health
records. Detailed evidence to support outcome
16 was requested and provided to the inspection
team for review.
ENHT was found to be fully
compliant with all the essential standards
inspected.
The inspection team found that people spoken
with had experienced care and treatment that
Data quality
The ENHT submitted records during 2012/13 to the secondary uses service for inclusion in the Hospital
Episode Statistics which are included in the latest published data.
The percentage of records in the published data which included the patient’s valid NHS number and the
valid General Medical Practice Code was:
Included valid NHS
Number
99.6%
Included valid General
Medical Practice Code
98.6%
Out patient care
99.8%
99.4%
Accident & Emergency care
98.7%
97.6%
Admitted patient care
Information Governance
Information governance is about ensuring that information such as personal records is properly
managed. Such information, whether paper or electronic needs to be cared for properly which means
stored safely and accessed only by the right people.
The ENHT’s Information Governance Assessment Report overall score for 2012/13 was 89% and was
graded ‘satisfactory’. The scores (%) for each standard are given in the table below.
Plan for
12/13
Achieved at
Level 2
86
86
Satisfactory
88
92
92
Satisfactory
75
77
77 or 80
84
Satisfactory
83
93
93
100
100
Satisfactory
Secondary uses
78
87
91
95
95
Satisfactory
Corporate information
58
77
77
77
77
Satisfactory
Overall
77
83
85
87 or 88
89
Satisfactory
Initiative
09/10
10/11
84
86
86
76
88
Information security
71
Clinical information
Information Governance
management
Confidentiality & data protection
East and North Hertfordshire NHS Trust | Quality Account 2012/13
11/12
12/13
39
Clinical coding error rate
The ENHT was subject to the Payment by
Results clinical coding audit during the reporting
period by the Audit Commission and the error
rates reported in the latest published audit for
that period for diagnoses and treatment coding
(clinical coding) are given in the table below.
Coding Department which helps to ensure
accurate information. This has led to a number
of improvements in the way clinical information
is documented in the patient medical record and
in the way that the Coding Department interpret
that information.
ENHT has taken the following actions to
improve data quality:
Senior clinicians from the Medical Director’s
office continue to work with the Clinical Coding
department to spread this good practice and
further optimise clinical input into the coding
process.
A number of Trust clinicians regularly review
coded activity with colleagues in the Clinical
Audit Commission
Information Governance
Clinical Coding Audit
10.0%
9.5%
Secondary diagnoses incorrect
7.4%
6.7%
Primary procedures incorrect
15.2%
5.6%
Secondary procedures incorrect
16.2%
13.4%
Primary diagnoses incorrect
Summary Hospital Mortality Indicator (SHMI)
SHMI—what is this?
SHMI measures deaths that happen at hospital and within 30 days of discharge. It is the ratio between
the actual number of patients who die following a treatment at the Trust and the number that would be
expected to die on the basis of average England figures, given the characteristics of the patients treated
there.
Indicator
a
b
Value of the summary hospital-level mortality indicator (“SHMI”)
Banding of the summary hospital-level mortality indicator
(“SHMI”)
Percentage of patient deaths with
palliative care coded at either diagnosis or
specialty level
The figures in brackets [ ] are the national figures.
The ENHT considers that this data is as
described for the following reasons:
The latest SHMI for the period Oct 2011 to Sept
2012 is 1.11. This places the Trust in 129th
position nationally out of 142 Trusts. Although
higher than average the chart on page 41 shows
an improving position. This figure now lies within
the expected range.
Mortality monitoring includes reviewing ‘alerts’
East and North Hertfordshire NHS Trust | Quality Account 2012/13
July 11-June
12
1.10
Oct 11 – Sept
12
1.11
2
2
35.8% [18.4%]
37.6% [18.9%]
which show higher than expected mortality with
certain diagnoses. This has been seen in five
areas: respiratory infection, urinary infection,
acute renal failure, septicaemia and congestive
heart failure. The care and treatment of patients
with these conditions have been reviewed during
the year and updated processes put in place.
However, it will be some time before
improvements are shown in the SHMI data as
there is a significant time lag of approximately 820 months before the reporting month ie. data
from January– December 2012 is due to be
reported in July 2013.
40
Source: Dr Foster Intelligence Mortality Comparator tool
140.0
130.0
120.0
110.0
Relative Risk
The chart shows a
rolling 12 month
trend for SHMI,
adjusted SHMI
taking into
account palliative
care, HSMR and
the 100 average.
ENHT SHMI (including adjustment for palliative care) vs HSMR
Rolling 12-mth Trend
Oct '10/ Sep '11 to Apr '12/ Mar '13
100.0
90.0
80.0
70.0
60.0
SHMI
SHMI with Palliative Care adjustment
The Trust is one of eight nationally that offers
hospice care as part of our services. This means
that patients admitted for end of life (palliative)
care who then die are included within the SHMI
figure. As a consequence the SHMI figure for the
Trust is likely to be higher than national average.
The Trust has reviewed data to understand the
influence of this palliative care effect. Dr Foster
confirms that our hospice makes a 5% difference
to our SHMI figure. When removing the palliative
care influence, the SHMI is at 101.1 (source: Dr
Foster). The overall improvement in SHMI reflects the falling HSMR trend.
The ENHT has taken the following actions to
improve the indicator and percentage in (a) and
(b), and so the quality of its services, by:
•
•
•
•
Ongoing review of recently reconfigured
services (e.g. fractured NoF, emergency
surgery)
Joint working with Dr Foster to understand
the data more thoroughly
The nomination of Clinical Coding Leads by
Clinical Directors for all relevant specialties to
improve familiarity and accuracy
A clinician and senior coder meet regularly to
review the clinical quality and coding
accuracy of patient deaths. This is well
established in the Fractured Neck of Femur
service and Care of the Elderly and is being
rolled out to other medical specialties
East and North Hertfordshire NHS Trust | Quality Account 2012/13
SHMI (adjusted for palliative care)
•
•
•
HSMR
100 Average
A joint mortality review group with West
Hertfordshire NHS Trust and NHS
Hertfordshire has been set up
The frequency of meetings of the Clinical
Coding Review Group has been increased to
every 2 weeks
Shared learning with other Trusts eg test
result assisted coding
Aiming High Award
Swichboard teams, Lister & QEII Hospitals
January 2013
Staff from the Trust’s main switchboard at the
QEll and Lister hospitals received the award
for their hard work and dedication during a period of significant change. They have ensured
that the service remained excellent and that
people have been connected to the right consultant, ward or office, speedily and with the
minimum of fuss.
41
Patient Reported Outcome Measures (PROMS)
PROMS—what is this?
Patient Reported Outcome Measures (PROMs) were introduced in 2009. Each patient undergoing four
types of surgery as listed below are asked to complete questionnaires before and after surgery. The
information is compared and improvements noted. There are a number of ways of measuring the
improvements, one of these - the EQ-5D index health gain – is given. This is an overall weighted
assessment relating to function and feeling. The measure ranges from -0.594 to 1 where 1 is the best
possible state of health.
Indicator
a
Groin hernia surgery
b
Varicose vein surgery
c
Hip replacement surgery
d
Knee replacement surgery
April 2011-March 2012
0.081
[0.087]
Data numbers too low for
analysis
[0.094]
0.414
[0.416]
0.316
[0.302]
April 2012Dec 2012
Number too low for analysis
[0.090]
Not featured
[0.089]
Number too low for analysis
[0.429]
Number too low for analysis
[0.321]
The figures in brackets [ ] are the national figures.
The ENHT considers that this data is as
described for the following reasons:
The April 2011-March 2012 data contains a mix
of procedures undertaken by ENHT for the first
half of the year and by both ENHT and the
sugicentre for the second half of the year.
Routine procedures where surgery is expected to
be straightforward are undertaken at the
surgicentre; whereas more complex operations
are undertaken at ENHT. The data for this period
is not separated (and cannot be separated) so it
is not an accurate reflection of outcomes.
However, where data is available for this period
the outcomes are consistent with national
averages.
ENHT but we were surprised to see, in January
2013 when the data was released, that the Trust
was not featured in the analysis figures.
Further investigations revealed that the process
to identify the different surgicentre and nonsurgicentre patients was not adequately set up.
The ENHT has taken the following actions to
improve these outcome scores, and so the
quality of its services, by working with the survey
coordinators to ensure that the correct data is
captured and that their systems adequately
differentiate between Trust and surgicentre
patients. The Trusts surgical division will ensure
that processes are robust within clinics and preassessments to ensure patients receive the
appropriate questionnaire.
The majority of these procedures are undertaken
at the surgicentre so data for April – September
2012 was expected to show low numbers of
patients associated with ENHT. The Trust was
eager to see how patients felt they had benefited
from the more complex operations undertaken at
Readmissions
a
b
Indicator
Percentage of patients aged 0 to 14 readmitted within 28 days of
discharge
Percentage of patients aged 15 and over readmitted within 28 days
of discharge
2009/10
11.02
[10.18]
11.09
[11.16]
2010/11
13.73
[10.15]
10.57
[11.42]
The figures in brackets [ ] are the national figures.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
42
The ENHT considers that these percentages are
as described because it is historic data. The most
recent data shows the readmission rate to be
11% across the organisation for 2012/13 and is
featured on the Trust floodlight rated ‘amber’. The
Trust is aiming towards a 9% readmission rate.
Historical data can be found on page 51 of this
report.
Management Programme. ‘Increasing
Ambulatory Care and Reducing Readmissions’
is working towards ensuring that those who
need additional services or care after discharge
can be seen and have their needs met by
attending hospital just for a day, rather than
requiring an admission. The ‘Effective
Discharge Planning’ workstream aims to ensure
that patients, once discharged, have their needs
met fully by all services eg social services,
community nursing etc and therefore do not
require a later readmission due to a failure of a
care package or insufficient preparation.
The ENHT has taken the following actions to
improve these percentages, and so the quality of
its services, by introducing two workstreams in
2012 as part of the Transforming Inpatient
Responsiveness to Personal Needs
Indicator
a
Responsiveness to the personal needs of patients
2010/11
64.6
[67.3]
2011/12
64.8
[67.4]
The figures in brackets [ ] are the national figures.
The ENHT considers that this data is as described for the following reasons:
•
•
Continuing poor scores relating to finding someone to talk to about worries and fears
Continuing poor scores relating to informing patients about medication side effects
The results are summarised below for the five questions making up the composite score for this
indicator.
Question
Were you involved as much as you wanted to be in decisions about your care
and treatment?
Did you find someone on the hospital staff to talk to about your worries and
fears?
Were you given enough privacy when discussing your condition or treatment?
Did a member of staff tell you about medication side effects to watch for when
you went home?
Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital?
Overall
This indicator forms part of the CQUIN score for
2012-13. A score of 66.2 derived from the
national inpatient survey results means that
although improvements have been made overall,
the CQUIN target of 67 was not achieved.
The ENHT has taken the following actions to
improve this data, and so the quality of its
services, by:
•
•
Raising awareness of these questions via the
performance reviews
Introducing the ARC programme and more
latterly the Excellence in Customer Care
programme
East and North Hertfordshire NHS Trust | Quality Account 2012/13
•
•
•
2010
71.3
2011
68.8
2012
69
57
54.9
52
76.3
78.8
81
46.2
45.2
50
72.3
76.1
79
64.6
64.8
66.2
Undertaking a skill mix review on the wards in
January to see if staffing numbers and grade
of staff are in line with national averages
Introducing mobile units to dispense
medications on the ward. Pharmacists can
therefore educate patients about their
medication
Incorporating a question about providing
medication-related information into the
discharge checklist.
43
Recommending the Trust
Indicator
Percentage of staff employed by the Trust who would recommend the Trust as a provider of care to their family or friends
2011
2012
57%
[60%]
66%
[63%]
The figures in brackets [ ] are the national figures.
The ENHT considers that this percentage is as
described because of the organisational changes
underway; the commitment to improve quality
and the focus on staff development.
•
The ENHT has taken the following actions to
improve this percentage, and so the quality of its
services, by:
•
•
•
Increased internal correspondence about
the quality of care delivered
Involvement of staff in the service changes,
so there is a sense of ownership about
future services
Focusing on the Trust values as a way to
galvanise staff into delivering a service that
they would want for themselves
Dedicating a considerable amount of time
to the ARC staff development programme
so that managers are more aware of quality
outcomes and can share this with their staff
Venous thromboembolism
Indicator
a
Percentage of patients who were admitted to hospital and who were risk
assessed for venous thromboembolism
JulySept
2012
SeptDec
2012
99.3%
[93.8%]
99.4%
[94.1%]
The figures in brackets [ ] are the national figures.
The ENHT considers that this percentage is as described because of the continued efforts to promote
and monitor VTE assessments on a daily basis. These figures continue to exceed the national figures.
The ENHT has taken the following
actions to improve this percentage,
and so the quality of its services, by:
•
•
•
•
Continuing to collect data on a
daily basis and publish the
analysis at ward and consultant
level
Monitor the outcomes on the
Board floodlight as well as at
performance reviews
Incorporating the assessment
form into a revised medication
chart so that they are readily
available and completed as part
of the everyday treatment plan
Assessing completion during
safety walkabouts
100
80
60
40
20
0
East and North Hertfordshire NHS Trust | Quality Account 2012/13
Jul-Sept
(2010)
OctDec
Jan-Mar Apr-Jun Jul-Sept
(2011)
Trust
OctDec
England
Jan-Mar Apr-Jun Jul-Sept
(2012)
OctDec
Aim
44
Clostridium difficile
Indicator
The rate per 100,000 bed days of cases of C.difficile infection reported
within the Trust amongst patients aged 2 or over
a
2010/11
20.8
[29.6]
2011/12
4.1
[21.8]
The figures in brackets [ ] are the national figures.
The ENHT considers that this rate is as described
because of the significant improvements made
within infection prevention and control over the
last few years as can be seen in the graph below.
The ENHT has taken the following actions to
improve this rate, and so the quality of its
services, by:
•
•
No. clostridium difficile by year
400
350
•
•
300
250
200
•
•
150
100
50
0
2007-8
2008-9
2009-10
2010-11
2011-12
2012-13
Monitoring at division and ward level
Ensuring divisional leads feedback their
infection control initiatives at the Trust
Infection and Prevention Control
Committee
Enforcing ‘naked below the elbow’
Mandating handwashing training for all
staff
Monitoring the high impact interventions
Undertaking root cause analysis of
surgical site infections to identify, and
rectify, any gaps in understanding or poor
practices
Number of patient safety incidents
Indicator
a
The number of patient safety incidents reported within the Trust
b
The rate of patient safety incidents reported within the Trust
Percentage of severe harm or death [Large acute Trust average]
Oct 2011March 2012
4589
(4880)*
9.49
0.6%
(0.7%)*
[0.7%]
April – Sept
2012
4678
(4752)*
10.84
0.3%
(0.3%)*
[0.7%]
The figures in brackets [ ] are the national figures.
The ENHT considers that these numbers and rate
are as described because of the strong reporting
culture within the organisation and the willingness
to be open about our incidents.
The ENHT has taken the following actions to
improve this number and / or rate, and so the
quality of its services, by:
•
* Please note that updated figures are reported in
brackets ( ). This takes account of the additional
incident report forms received by the risk
management department after the date when the
data upload was sent to the national system. The
Trust is pleased to send regular data uploads to
the national system but recognises that not all
data will be captured whilst having a paper
incident reporting system.
•
•
•
•
East and North Hertfordshire NHS Trust | Quality Account 2012/13
Continuing to encourage the reporting of
incidents and supporting staff when
completing investigations
Promoting an open culture
Including summary data relating to serious
incidents by division as part of the monthly
rolling half day learning package
Developing the skills of senior staff in
undertaking investigations and supporting
them to do so, thereby promoting the
opportunity for learning and openness
Offering root cause analysis training
45
Electronic incident reporting
The Trust has started to introduce Datix-web for electronic capture of incidents, rather than paper forms.
Whilst still in its early stages of implementation already the value of easy access to specific incidents
and overall trends analysis is becoming evident to users. The electronic incident form also mandates
that when a patient suffers harm there is an acknowledgement of ‘being open’ and a requirement to
state when such discussions with the patient / their family occurred.
Results of the
2012 NHS Staff
Survey indicate
that the Trust is
better than
average for the
fairness of
incident
reporting.
More recent data, (April –
Sept 2012) shows the
Trusts performance
against 39 large acute
organisations. The rate of
reported incidents is at
10.8 per 100 admissions.
This is shown in the graph
and demonstrates the
Trust as the third highest
reporter.
The severity of incidents, again
for April – Sept 2012, is shown
here.
This profile is indicative of an
organisation with a
mature incident reporting culture.
(Source: NHS Commissioning
Board, March 2013)
East and North Hertfordshire NHS Trust | Quality Account 2012/13
46
Part 3
3a Review of quality performance in 2012/13
Overview
Quality can be broken down into three areas: safety, effectiveness and experiences of care. Examples
of changes or improvements in each of these areas for the last year are given.
Key:
The key is based upon the thresholds set by the Board at the beginning of each year which are used to
monitor performance throughout the year.
Achieved
~
Under achieved (defined mid-range as given on the Trust floodlight)
Not achieved
Organisation summary
The East and North Hertfordshire NHS Trust
provides secondary (hospital) and limited tertiary
(specialist) care services from four sites:
•
•
•
•
The Lister Hospital in Stevenage
The Queen Elizabeth II (QEII) Hospital in
Welwyn Garden City
Hertford County Hospital in Hertford
Mount Vernon Cancer Centre in Northwood,
Middlesex
The first three sites provide services to a
population of around 600,000. Mount Vernon is
one of the country’s leading cancer treatment
centres, serving a population of some two million
people.
The income for 2012/13 was approximately
£346m (including non-NHS activities and other
income) and over 5,000 staff are employed by
the Trust.
Clinical services are organised into five
Divisions. Four Divisions (Medicine, Surgery,
Cancer and Women/Children’s) offer treatment,
while the fifth (Clinical Support) provides
Pathology, Radiology, Pharmacy and Medical
Records services.
The Lister and the QEll hospitals provide a range
of acute services, outpatient and diagnostic
services. Hertford County Hospital is a diagnostic
and outpatient centre.
A number of specialist services are also provided.
These are:
•
•
•
The Mount Vernon Cancer Centre providing
specialist chemotherapy and radiotherapy
services
Urological cancer
Renal medicine and plastic surgery at the
Lister Hospital. The Renal service has been
expanded to incorporate the management of
the satellite unit at Bedford
East and North Hertfordshire NHS Trust | Quality Account 2012/13
Equality Delivery System
The Trust has adopted the Equality Delivery
System (EDS) aimed at improving the equality
performance of the NHS and embedding
equality into mainstream business. For more
details please refer to http://www.enhertstr.nhs.uk/about-the-trust/equality-diversity
47
Patient safety
The Patient Safety Strategy (2011-14)
summarises intentions to:
•
•
Reduce harm and avoidable deaths
Promote a culture whereby safety is an
integral part of what we do
Design services, pathways and systems to
protect patients from harm
•
In 2012/13 the strategy was supplemented by a
set of objectives. These are summarised in the
table below together with an indication as to
whether, or not, they were met.
Twelve patient safety walkabouts were
undertaken during the year, against a plan of 40.
This is simply because of other safety initiatives
taking priority. The totality of monitoring at the
ward level is such that any emerging concern will
trigger a safety walkabout. A walkabout plan for
2013/14 will be revised so that it is risk based and
will allow for a more in-depth review of fewer
areas rather than a broad overview of many.
The consent action plan was intended to further
improve consenting practices. Some aspects of
the action plan have been implemented, such as
additional training. However it has not been
possible to introduce the range of combined
consent forms / information leaflets as had been
planned. This work will continue into 2013/14.
1
Global Hand Hygiene Day
Promoting the ‘flu jab’
“Dreadful se
rvice,
thankfully th
e op went
well”
(Paediatric
s/
Theatres, Fe
bruary
2013)
Priority
Undertake revised patient safety walkabout programme, reporting findings to PSC
bi-monthly
2
Implement ‘diabetes action plan’ focusing on insulin error reduction and management
of the diabetic foot. Monitored at Medication Forum, escalated to PSC bi-monthly
3
Review medication errors at Medication Forum & report to PSC bi-monthly (focus on
anticoagulation & delays in critical medicines)
4
Review handover process to make shift & out of hours handovers more robust. Update
policy
6
Reduce falls / pressure ulcers, VTE and catheter acquired urinary infections as per
Safety Thermometer
Introduce the SBAR communication tool
7
Implement ‘Sepsis action plan’
8
Consent – implement NHSLA action plans to ensure consent is sought by appropriately
trained staff and that the supporting information is improved
9
Introduce Datix web for the real-time logging of incidents in the local area
10
Complete ‘policies action plan’ so that all trust-wide policies / guidelines on the KC are
edited (edit screen) to maximize accessibility via keyword search
5
East and North Hertfordshire NHS Trust | Quality Account 2012/13
Met
48
Safety indicator set
The following indicator set gives an overview of some of our safety indicators with results over the last
few years.
Indicator
Medication errors
Fractures following falls in hospital
Never events
MRSA Elective Screening (all elective inpatient admissions)
MRSA Bacteraemia
Number of falls
NHS Safety Thermometer
09/10
10/11
11/12
12/13
Plan for
12/13
Met
N/A1
N/A
1438
1176
1250
1175
15
24
29
21
N/A
1
1
1
2
0
N/A
92%
99.5%
99.9%
100%
10
5
3
2
3
1841
2058
1650
1216
<1237
N/A
N/A
N/A
498
589
N/A
The Trust wishes to encourage open reporting of incidents so no targets are set for this indicator
Never events
The Trust declared two ‘never events’ in the year.
These are incidents that should never happen if
good preventative practices are in place.
A swab was left in the abdomen of a patient
following obstetric surgery. Further surgery was
required to extract the swab which at some point
had been missed. The initial surgery had been
particularly difficult with significant blood loss and
additional consultant staff had been called to assist
in the operation. Two further operations were
undertaken to control bleeding and a fourth
operation to remove the swab. It is not clear at
what point the swab was left in place. The
investigation revealed a number of factors
contributing to the incident such as poor swab
counting practice in an emergency situation;
unfamiliarity of the team in the obstetric theatre;
multiple consultant cover and handover of care. A
comprehensive action plan was produced and is
being implemented which aims to align obstetric
theatre practices with those of main theatres.
A patient underwent surgery on his spine involving
vertebrae L3/L4 (lower back region). The surgery
was intended for the adjacent vertebrae L4/L5 and
a further procedure was required to relieve the
initial problem. The investigation is currently
underway.
Safety alerts
All relevant national patient safety alerts have been
implemented. The monitoring of alerts is a standing
item of the Patient Safety Committee.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
Eastern Academic Health Science Network
The Trust is participating in the Eastern
Academic Health Science Network. This is a
regional programme of initiatives to improve
patient safety.
Working alongside academic establishments
the aim is to research new ways of improving
safety and sharing the learning amongst the
network organisations. It is in the early stages
of development with projects being identified
such as learning from incidents, improving
handover of test results and designing systems
to prevent error.
“The nu
rse gave
us very
clear in
struction
s about
how to m
anage th
e wound
once we
got hom
e, and
spoke to
both me
a
nd my
daughte
r in sim
ple,
reassurin
g terms
t
h
a t we
could u
ndersta
nd.”
(Paedia
trics, Ja
nuary 2
013)
49
Serious incidents
Serious incident data is reported nationally per
calendar year.
The inclusion of pressure ulcers and serious falls
has resulted in an increase in the number of
serious incidents reported.
The uncategorised incidents below relate to a
range of matters with the following themes:
•
•
•
As a consequence the Trusts safety initiatives
have focused on acting on test results, improving
handover, improving communication of critical
information and auditing the standard of
observations.
All serious incidents were investigated thoroughly
using root cause analysis techniques and action
plans implemented where failings were identified.
Missed diagnosis or late diagnosis
Failure to observe deterioration
Breach of confidentiality
Indicator
2009
2010
2011
2012
10
19
22
8
8
12
9
3
Pressure ulcers (reportable from November 2010)
N/A
0
26
49
Serious falls (reportable from April 2012)
N/A
N/A
N/A
6
18
31
57
66
Serious Incidents (uncategorised)
Healthcare acquired infection
Total
Examples of improving safety
Early Warning Score
Monthly audits show that observations of pulse,
blood pressure etc are undertaken correctly in
93% of cases. The launch of a new observation
chart, together with further training, aims to
increase this figure.
Sepsis
Blood infections may lead to someone dying if not
treated quickly and correctly. A review of sepsis
care has been completed and a new care
pathway put in place to guide treatment.
Handover
A review of handover and transfer of patients to
other teams has shown this to be a potential
source of error. To avoid ‘things getting missed’
new standards of handover and transfer have
been produced.
Urinary infections in patients with a catheter
Catheter infections are seen in less than 10% of
people with a catheter.
SBAR
This is a way of communicating critical
information when prompt action is required. The
method was introduced in July 2012.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
50
Clinical effectiveness
The Improving Patient Outcomes document
describes the Trusts intention to enhance the
effectiveness of care. Four aims have been
identified for focused action during the year:
•
•
•
•
Improving the timeliness of care
Reducing the variability of care
Reduction of error through improved
communication
Introduction of evidence based innovations
and therapies
Indicator
09/10
Effectiveness indicator set
The following indicator set gives an overview of
some of our effectiveness indicators and
changes over the last few years.
Specific details about HSMR can be found on
page 22, and SHMI on pages 40 and 41.
10/11
11/12
12/13
Plan for
12/13
HSMR (rebased)
101.9
99.3
98.21
92.7
<=89
HSMR (Medicine)
119.4
108.2
101.3
99.4
<=90
HSMR (Surgery)
124.6
115.5
96
83.5
<=90
HSMR (Cancer)
48
47.5
63.7
61.7
<=85
HSMR (Women & Children)
81.4
107.6
68.3
87.4
<=85
SHMI
SHMI (with palliative care
adjustment)
Emergency readmissions to
hospital within 28 days of
discharge*
% of patients spending 90% of
hospital stay on a specialist stroke
unit
% patients with high risk TIA seen
and scanned / treated within 24
hours (Not admitted)
% of admitted patients riskassessed for Venous
Thromboembolism
N/A
117.8
114.1
111.4
<=105
N/A
102.5
103.7
101.1
<=100
-
14.9%
15.04%
11%
9%
34%
91.4%
83.75%2
75%2
79.4%
80%
Underachieved
66.5%
39.2%
51.2%
60%
N/A
62.6%
92.8%
99.2%
98%
Met
~
~
~
~
1
HSMR - figure reported in the 2011/12 report of 93 was based upon the 2010/11 benchmark
The methodology changed in October 2011 from ‘time of admission’ to ‘time of arrival’ so the average data for quarters 1&2
and for quarters 3&4 are given separately. An average final year position is therefore not given as the data is not comparable
* 2 months in arrears
2
Aiming High Award
Renal Team
Our renal transplant team has received funding from NHS
Kidney Care towards a project aimed at enhancing patient
experience and health outcomes through timely listing for
transplantation. With the funding the team has invested in
staff training, engaged with other hospitals and reviewed
patient and staff communication; with positive feedback from
patients, relatives and colleagues across the Trust.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
51
Examples of improving effectiveness
Paediatrics
A peer review of the Trust’s paediatric emergency
department service was undertaken in March.
Early feedback from the visit suggests that the
Trust has one of the best developed services in
the region.
Linear accelerators at MVCC
Two new TrueBEAM linear accelerators are being
installed ready for use from the spring of 2013.
These are radiotherapy machines delivering
high-dose radiation treatment to patients with
cancer.
New interventional procedure
A new procedure called CT-guided renal
cryotherapy (freezing kidney tissue) has been
introduced to treat tumours at the back of the
kidney.
The procedure is undertaken in the radiology
department where the patient is anaesthetised,
face down.
The new machines
will be capable of
changing the shape
of the radiation
beam in real time
whilst the machine
rotates around the
patient.
This enables staff to plan treatments which
conform to the shape of the tumour and are
delivered faster than from a traditional machine.
Jagdeep Kudhail, radiotherapy manager at Mount
Vernon says:
“TrueBEAM technology is currently only
available in a handful of centres around the
world – and we are the only radiotherapy
department in the country with two of these
machines, which are replacing two older,
less sophisticated machines.”
Urology
The Trust has been recognised by the Royal
College of Surgeons as a national centre for
urological robotic training, making us the first such
centre anywhere in the country.
A probe (guided into place using the CT scanner)
is inserted into the kidney. Argon is then applied
via the probe to freeze the tumour.
The procedure means that open surgery and high
dependency care is not necessary; that the
patient has minimal scarring and pain; and most
importantly can go home after a few days.
Bedford Satellite Unit
Bedford’s first ever renal dialysis unit, being run
by the Trust, opened in April 2013.
The new unit can support the dialysis needs of
around 60 patients; most of whom come from the
Bedford area. The Trust’s general manager for
renal medicine, Bridget Sanders, says:
“We know that people from Bedford are
sometimes making daily trips to our existing
dialysis units [Lister and Luton & Dunstable
Hospitals], so having a service on the
doorstep will be great for them.”
The Trust is also developing a unit in Harlow and
once operational will mean the Trusts renal
dialysis service will act as a hub supporting four
satellite units in St Albans, Luton, Bedford and
Harlow - making the service one of the largest in
Eastern England.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
52
Patient experiences
Patient and Carer Experience Strategy
The Strategy for 2012-15 sets out seven
ambitions for excellence in patient carer
experience.
Experiences indicator set
The following indicator set gives an overview of
some of our experiences indicators and changes
over the last few years.
Indicator
09/10
10/11
2011/12
2012/13
Number of complaints
902
889
1063
969
Complaints – care
182
142
140
113
Complaints – communication
326
299
402
385
55%
37%
57%
26
58%
Complaints – response within 25 days
34
Ombudsman investigation
3
2
2
7
Complaint per level of activity
0.8%
0.7%
1.07%
1.08%
Number of PALS concerns
2347
1819
1733
1724
Meridian compliance
N/A
N/A
N/A
98.3%
Mixed sex accommodation breaches
Percentage of bed moves of people with dementia
(Compliance with standards to minimise moves)
N/A
0
0
0
-
-
0
0
Complaints
The number of complaints received in 2012/13
remains in line with the 2009/10 and 2011/12
figures. The increase in 2011/12 followed the
opening of the surgicentre.
•
•
Examples of learning and changes made to
practice arising from complaints are follows:
•
Following a complaint regarding
communication with a patient regarding their
outpatient appointment, all dictated letters
will be checked against clinic lists to ensure
accuracy of patient details
•
36
30
Local resolution meetings
Junior doctors to be given further education
in the process of communicating CT scan
results to patients
The Anaesthetic department are putting
procedures in place to ensure that cannulae
are flushed through post anaesthetic
induction
The Gynaecology Emergency Unit is to
display waiting times and arrange staff
training in breaking sad and difficult news to
patients
Complaints by Subject
(Top 6)
Analysis of
complaints over
the year shows six
main themes as
shown.
Treatment
received by
patient
Delay in
treatment/appoint
ment
Communication
w ith
patient/relatives
Attitude of staff
45
40
35
30
25
20
15
10
5
Discharge
0
2012 2012 2012 2012 2012 2012 2012 2012 2012 2013 2013 2013
04
05
06 07
08
09 10
11
12 01
02
03
East and North Hertfordshire NHS Trust | Quality Account 2012/13
Nursing Care
53
The 14 recommendations made in the Francis
report relating to complaints have been reviewed.
The Trust already meets many of these and notes
that many of the general criticisms contained in
the report are not features of the culture and
processes in our Trust. For example:
NHS Choices
NHS Choices is the country’s biggest health
website, providing patients with useful information
to enable them to make choices about their
health, and also as a means of giving feedback
about their experiences.
•
The Trust responds promptly to all feedback
regarding its services placed on the NHS Choices
website and, where appropriate, the author is
asked to get in touch to provide further details so
issues can be investigated. The Trust also
reviews comments left on the Patient Opinion
website in the same way.
•
•
•
•
•
The Chief Executive personally reads and
signs complaints responses
The Director of Nursing reviews all
complaints sent for investigation
Complaints trends and themes are reviewed
by the RAQC
Complaints review forms part of the
Divisional Performance reviews
All complaints are triaged on receipt to
ensure the appropriate level of investigation
is undertaken
Those making the judgement on whether a
complaint is upheld or not are independent
from the clinical setting where the incident
arose
Examples
of feedback are
given throughout
the report on these
‘notes’
The following is the summary screenshot of views
about our two main hospitals from NHS Choices.
Lister Hospital
QEII Hospital
Source: NHS Choices, 2nd April 2013
Lister hospital: http://www.nhs.uk/Services/hospitals/PatientFeedback/DefaultView.aspx?id=876
QEII hospital: http://www.nhs.uk/Services/hospitals/PatientFeedback/DefaultView.aspx?id=1064
East and North Hertfordshire NHS Trust | Quality Account 2012/13
54
The following provides a summary of the numbers and themes of feedback received via NHS Choices
from October- December 2012.
National In-patient Survey
342 patients responded to the survey, with a 42% response rate (51% nationally).
Emergency / A&E department
6.9
Waiting lists & planned admissions
6.2
2011
Comparison
to other
Trusts
Worse
Same
Waiting to get to a bed
7.1
Same
6.9
Same
9.6
Hospital & ward
7.7
Worse
7.7
Worse
9
Doctors
8.1
Worse
8.2
Same
9.4
Nurses
8
Same
8.2
Same
9.4
Care & treatment
7.1
Same
7.3
Same
8.8
Operations & procedures
8.3
Same
8
Same
9.1
Leaving hospital
6.7
Same
7.2
Same
8.7
Overall views & experiences
5.9
Same
5.2
Same
6.6
Question
Trust
Highest
national
score
9.5
8.7
2012
Comparison
to other
Trusts
Same
Same
Trust
8.2
9.7
Note: the scores are out of 10
The most significant improvements since 2011
relate to:
•
•
These improvements largely reflect the work
undertaken to improve customer care, through the
ARC programme; and also the efforts to improve
discharge planning, for example through the use
of mobile dispensing units.
•
•
discharge not being delayed by waiting for
medicines, to see a doctor or for an
ambulance
receiving answers to questions in a way that
could be understood
receiving written information about what to
do after leaving hospital
East and North Hertfordshire NHS Trust | Quality Account 2012/13
receiving information about danger signals
(things to watch out for) when going at home
55
The most significant decline since 2011 relate to:
•
•
•
•
receipt of copies of letters sent to the family
doctor
sharing the same bathroom / toilet with
patients of the opposite sex
noise at night from other patients
insufficient information when planning for an
operation eg. risks and benefits
The Trust is particularly disappointed by the noise
at night scores given the attempts made over the
last few years to make improvements.
Patients are offered ear plugs and night-time
activity is minimised where possible. A new ward
block, due to be opened in summer 2014, will
help to alleviate this as half of the rooms are
single rooms. Until then the Trust will continue to
seek new ways to make improvements.
Action planning is underway at the time of writing
the report.
National A&E Survey
271 of 850 (32%) of
patients who visited the
accident and emergency
department in early 2012
responded to the national
questionnaire.
A selection of the scores,
compared with the
previous survey in 2008
and with the highest
national are given.
Question
Overall did you feel you were treated with respect and dignity while you
were in the A&E Department?
Were you given enough privacy when discussing your condition with
the receptionist?
How long did you wait before you first spoke to a nurse or doctor?
2008
2012
Highest
national
score
8.6
8.6
5.8
6.5
8
6.9
6
7.7
9.4
Were you involved as much as you wanted to be in decisions about
your care and treatment?
Do you think the hospital staff did everything they could to help control
your pain?
How clean was the A&E Department?
7
7.8
8.4
7.5
6.5
8.3
7.3
7.9
9.3
How clean were the toilets in the A&E Department?
6.9
7.9
9.2
The Trust is currently developing an action plan in response to this survey.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
56
Patient Experience Trackers – Meridian Results
Electronic surveys are widely undertaken
throughout the Trust. The number of responses Survey
to some of these surveys are given in the table.
Inpatient
For each of these surveys the top three ranking
scores and the bottom three ranking scores are
given in the four tables below.
Response Totals 2012/13
7127
Outpatient/day case
5144
Maternity
2011
A&E
1147
A maximum score is 100.
In-patient electronic survey (April 2012-March 2013)
Did you feel you were treated with respect and dignity while you were in the hospital?
96.93
Were you offered a choice of food?
96.04
In your opinion, how clean was the hospital room or ward that you were in?
94.17
How would you rate the hospital food?
68.47
Were you ever bothered by noise at night from other patients?
67.02
Did you have somewhere to keep your personal belongings whilst on the ward?
63.16
A trial of lockable safes has taken place and quotes obtained for purchase and installation of the
preferred safe. A business case for capital monies to install a lockable safe in each bedside locker is
being prepared.
Out-patient electronic survey (April 2012-March 2013)
Overall, did you feel you were treated with respect and dignity in the Department?
98.53
Were you given enough privacy when discussing your condition or treatment?
97.20
Did the doctor / health care professional explain the reasons for any treatment or action in a way that you could understand?
95.73
How long after the stated appointment time did the appointment start?
68.59
Were you given a choice of appointment time?
63.58
On arrival were you told how long you would have to wait?
52.87
Reception staff have been reminded to inform patients verbally of any anticipated delays to their appointment time when they book in; notice boards in outpatient clinics are regularly updated with details
of delays in appointment times.
Maternity electronic survey (April 2012-March 2013)
Were you offered a choice of food?
99.35
Was the reason for the 20-week scan clearly explained to you?
98.87
Thinking about your care during labour and birth, were you spoken to in a way you
could understand?
Thinking about feeding your baby (breast or bottle) did you feel that midwives and
other carers gave you consistent advice?
97.64
89.87
How would you rate the hospital food?
70.03
If you had an episiotomy (cut) or tear requiring stitches, how long after your baby was
born were the stitches done?
65.08
Staff have been encouraged to suture within an hour of birth but not to interrupt skin to skin contact with
mother and baby.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
57
Emergency Department electronic survey (April 2012-March 2013)
Overall, did you feel you were treated with respect and dignity while you were in the
A&E Department?
97.96
If you needed attention, were you able to get a member of staff to help you?
96.36
Do you think hospital staff did everything they could to help control your pain?
95.31
Did a member of staff tell you about any danger signals regarding your illness or treatment you should watch for after you went home?
In your opinion, how clean was the hospital room or ward that you were in?
How clean were the toilets and bathrooms that you used in hospital?
92.59
90.96
85.93
Examples of improving patient experience
Mobile Dispensing Units
Some medications
can now be dispensed
by ward pharmacists
on the wards using
mobile dispensing
units.
Knit and Knatta
Linda Mylrea advises…
The pharmacy team won the continuous
improvement award for this initiative.
Andrew Hood, chief pharmacist, and Rachel
Sporton, deputy chief pharmacist said:
“The new mobile dispensing units mean that
medicines for patients to take home can now
be dispensed on the ward, reducing patient
waiting time and giving patients face to face
contact with a pharmacist. The new system
has made a real difference to patient
experience.”
Continuous Improvement Winners
Pharmacy Team
The Knit'n'Knatter group started in February
2012. It is a group of sociable ladies with time to
knit and no-one to knit for.
The group knits a vast array of items, including
blankets, shawls, bedsocks and have provided
items to the maternity unit, neonatal unit and
elderly care wards.
Surplus goods have been given to both the
Women's Refuge in Stevenage and also to
Mercy Ships.
At Christmas the group gave 90 wrapped and
knitted gifts to each of the elderly care wards for
their patients to open on Christmas day.
Hertford County Hospital pre-operative
assessment
A new pre-operative assessment service for
surgical patients at Hertford County Hospital has
opened.
This means the majority of surgical patients can
have their assessment completed immediately
after their clinic appointment. This service
reduces the number of visits that patients have
to make to the hospital, ensures that they are fit
for surgery, provides an excellent opportunity for
the nurse to explain about the proposed surgery
and gives the patients time to ask questions.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
58
Kissing it Better
Kissing It Better is a charity who’s work aims to
improve patients experiences by recruiting
community volunteers to attend hospitals to
provide some form of therapy or care. The charity
launched its first project in the East of England at
the Lister hospital.
Beauty therapy students from North Hertfordshire
College visit weekly to provide hand/arm
massages and manicures; and have attended the
childrens ward for face-painting sessions.
Adem and his PAT
dog Yogi continue to
be regular ward
visitors.
Patient Stories
To hear, first-hand, the views of patients senior
staff visit patients on wards and also ask some
people who have complained to come back and
describe their experiences.
This helps us to address immediate concerns
but also consider how we can improve services
in the future. Feedback is shared with the staff in
the relevant area and also to staff as part of the
Trust staff development programme.
The Trust has welcomed patients attending
Board meetings to talk about their experiences.
Positive themes have included the friendliness
and dedication of staff; communication with
doctors daily and being reassured whilst waiting
for surgery.
A group of children aged 9+ from Heath Mount
School sang in the day room on Pirton and Barley
wards, singing songs that the elderly patients were
familiar with. The Brownies of Bengeo and the
Stevenage Community Choir have also provided
choral entertainment.
Liz Pryor, East of England Coordinator
commented to the Trusts Grapevine
Magazine
“We are also pleased to be working
with two local volunteers via the Pets
for Therapy charity – who are bringing
their dogs to visit patients, and make
people smile!”
East and North Hertfordshire NHS Trust | Quality Account 2012/13
Negative themes have included communication
around investigations, tests not being done
quickly and noise at night.
re
need mo
“The staff
speak
n how to
o
g
in
in
tra
ost of
atients. M
to their p
rude
extremely
e
r
a
m
e
th
h they
as thoug
and seem
be
n want to
don't eve
there”.
ne
y Dept, Ju
c
n
e
g
r
e
(Em
2012)
59
3b Our staff
Overview
Results of the 2012 staff survey show better than average performance, against all acute Trusts, in over
half of the questions asked. This is encouraging given the significant investment in staff training and
development, through the organisation development programme and various leadership development
courses. The survey findings also demonstrate performance which can be aligned with our Trust values.
This section also recognises the achievement of individuals, including volunteers, and provides a
summary of their awards.
Staff indicator set
The following results are from the national staff surveys.
Key Indicators
10/11
11/12
12/13
Staff engagement
% staff who would recommend the provider to friends or
family needing care (composite of agree & strongly
agree)
3.61
3.63
3.72
National
average
3.69
60
57
66
60
Staff development
A programme of organisational culture change,
known as ARC, was launched in 2011 as part of
the Organisation Development Strategy.
The intention is to further develop
staff and their skills, increase
staff involvement, develop
leadership and improve the
environment in which staff work.
Accelerate: quality, staff training,
communication
Refocus: on our patients, on our staff,
on our values, on our partners
Consolidate: services, patient pathways,
our hospitals, our teams
During 12/13 there were four ARC sessions
delivered to line managers dedicated to the
following subjects:
•
•
•
•
Outcomes of the 2011 Staff Survey
Team working
Customer care
Resilience to lead during time of change
The customer care session for managers marked
the start of a Trust-wide excellence in customer
care programme for all staff. It is intended, with
the help of an external training company, that all
staff will receive the training aimed to deliver
excellent customer care consistently day in and
day out.
East and North Hertfordshire NHS Trust | Quality Account 2012/13
Management and leadership
Julia Seez, Training Officer writes...
“The Trust offers three management and
leadership development programmes, endorsed
by the Institute of Leadership and Management,
which means that the standard and quality of the
content and training has been externally
approved.
The programmes are aimed at different levels of
management:
•
•
•
team supervisors
managers of departments or wards
leaders of our services
They all provide the learners not only with skills
development on the workshops included, but
focus on the practical application of this learning
with reflections as part of their portfolio work as
well as 'on the job' coaching, for example
observations of care/service.
The consistent feedback is that not only have
their knowledge and skills of managing others
improved, but overwhelmingly how their
confidence has grown and their overall
knowledge of other departments and services
increased too.”
60
The effectiveness of these development
programmes can be seen below where examples
of actions to improve patient care by staff from the
2011/12 effective leaders programme, are given:
•
Jackie Cookman’s nurse-led pre-assessment
for patients with complex conditions
attending the endoscopy suite has been a
great success. She has now secured funding
for a larger trial
•
Chris Bates has reduced patient treatment
delays during dialysis by improving the
training for clinical support workers to solve
common dialysis machine faults
•
Mandy Northover introduced a meet and
greet service within the dialysis unit to
improve communication with patients about
their treatment times
•
Daison Zinyemba’s project led to a reduction
in the number of repeat blood sampling
procedures required from the accident and
emergency department
•
Heather Taylor introduced a document
control system to standardise procedures for
the numerous tests that take place in
Histology
•
Jenny Kilminster successfully led her team in
creating a ‘one stop shop’ pre-operative
admissions service
Effective Leaders
2012
Excellence in Supervision
programme achievers 2012
National staff survey
Staff surveys are undertaken annually as part of a
national programme. 350 Trust staff took part in
this survey - representing a response rate of 42%
which compares with a national response rate of
43%.
The results for 2012 show that performance was:
•
•
•
better than average for 15 (54%) of the 28
survey questions
average for 7 (25%) questions
worse than average for 6 (21%) questions
A summary of the results is shown in Appendix 1
with a selection of some of the results given below.
The annual national survey is supplemented with
in-house on-line surveys every four months. These
allow us to measure a range of cultural indicators
and identify trends to make improvements much
earlier than would otherwise have been possible.
Trust
2010
93%
75%
Trust
2011
92%
80%
Trust
2012
91%
84%
National
2012
89%
78%
Good communication with managers
27%
31%
26%
27%
Undertaking training
74%
76%
81%
81%
Equality & diversity training
38%
53%
74%
55%
Question
Role makes a difference to patients
Level of satisfaction with work and care
East and North Hertfordshire NHS Trust | Quality Account 2012/13
61
Aligning the national staff survey with Trust values
East and North Hertfordshire NHS Trust | Quality Account 2012/13
62
A note on discrimination
The Trust performed worse than average when staff were asked if they had experienced discrimination.
In response to the survey findings a Staff Survey Engagement Action Plan has been developed. The
Trust has approached the NHS Leadership Academy to share national learning with feedback to, and
involvement of, leaders during the ARC sessions.
Our volunteers
Janis Hall, Voluntary Services Manager writes…
“Some people think volunteering is something
only retired people do in order to fill their days –
not true! We have 900 volunteers across our four
sites: full time mums, empty nesters, successful
career men and women and, of course, our
retired volunteers, all of whom want to use their
skills outside their home or their workplace.
Some of our volunteers have been with us for
many years. The feedback we get is very
positive. Most of our volunteers say that coming
in to the hospital makes them feel useful, it gives
them a reason to get up in the morning and they
love to be among people who need them. Some
come here to gain experience so that they can
embark on a career in the NHS and they tell us
that the experience they get with us is invaluable.”
Our volunteers cover many traditional roles like
welcomers, drivers and ward assistants but we
use other skills too like journalism, crafts, IT and
administration. We need lots of different skills to
run an acute hospital service so if someone has a
skill we can use, it can be a perfect match!”
Celebration of Excellence awards:
volunteer winners
Jean Joyce
“Jean goes around with a
big smile on her face,
offering patients, staff and families refreshments.
She has a lovely manner and provides not just
drinks but also reassurance to many frail and
elderly patients.”
(Diana Hubbard, Clerical officer in the day
hospital)
Roz Whitfield
“Roz has spent 11 years
helping in different roles, recently starting to
work with new volunteers to support them as
they settle in. She has a flair for striking the
right approach with the right people and so
much happens because of her.”
(Janis Hall, voluntary services manager)
Angie Jones
“Angie helps patients by listening and explaining how the centre
can support them through their treatment. She is always calm and
empathetic and has a way of ensuring that complex situations are
handled sensitively to the benefit of patients and staff.”
(Rosemary Lucey, head of the Lynda Jackson Macmillan Centre)
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Celebration of Excellence Awards:
Long service awards
Acknowledging 25 years of volunteering at the Trust
Olympics 2012
Nicky Gilmour and Annabel Bradburn, both community
midwives, participated in the opening ceremony of the London
Olympics.
Nicky comments “Working in the stadium was incredible. The final
performance, which around a billion people around the world saw on
television, was the result of fantastic teamwork. It was truly a ‘once in a
lifetime experience’.
Dr Elizabeth Turner, a consultant in emergency medicine at the Lister
hospital, worked as a medical volunteer in both the Olympics and
Paralympics.
3c Our Changing Hospitals
‘Our Changing Hospitals’ is a major programme of change to services at the Lister and QEII hospitals.
The changes are phased and will run until 2014:
Phase
Status
1. Surgicentre
2. Maternity centralisation (includes
neonatal services and gynaecology)
3. Multi-storey carpark
Opened September 2011
4. Ward 11A refurbishment
Completed October 2011
4. Mortuary refurbishment
Completed October 2012
4. Critical care expansion
Completed December 2012
4. Ward 7A refurbishment
Completed December 2012
Opened October 2011
Opened September 2011
4. Health records centralisation
As planned
Due Summer 2013
4. Chemotherapy expansion
As planned
Due May 2014
4. New ward block
As planned
Due August 2014
4. Pathology
(see text)
Due Summer 2014
4. Theatres and endoscopy expansion
As planned
Due September2014
4. Emergency Department expansion
As planned
Due October 2014
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The first three phases have been completed and
were reported in last years Quality Account.
2012/13 has seen the completion of some
aspects of phase 4 and the approval for those
remaining.
Phase 4 is the final stage of redevelopment
dedicated purpose built pharmacy production
unit will eradicate the current problems
associated with production times for
chemotherapy drugs.
Work has begun to expand and develop the
Emergency Department which will provide:
costing £71.5 million.
•
The Critical Care Unit expansion was completed
which brings together the intensive care and high
dependency units from the Lister site and the high
dependency service from the QEII site. The new
unit has up to 20 beds, which will be used flexibly
in caring for patients. The new unit also has
improved facilities for our staff, as well for visitors.
Five critical care beds (mixed intensive care and
high dependency) remain at the QEII site to
support patients following surgery and/or those
who may deteriorate whilst on a hospital ward.
•
The Lister mortuary service has expanded and the
viewing, bereavement and waiting rooms have
been improved. This has provided an improved
environment for staff and public, and is more
conducive to privacy and dignity.
Ward 7A (Gynaecology) has been refurbished. It
contains dedicated inpatient beds, an early
pregnancy unit (including ultrasound), gynaecology
emergency unit and an ambulatory care service.
Thus it offers expertise in one place and a better
experience for women.
•
•
Specialist emergency and urgent care
services for both adults and children
Improved radiology services, including
a new CT scanner
Orthopaedic and fracture clinic –
moved to the hospital’s outpatients
department with its own dedicated
radiology support
An additional MRI scanner
Approval of the final aspects of the full business
case was given in December 2012 by the
Department of Health and HM Treasury. Upon
approval Health Minister Lord Howe said:
"The development plans for the Lister
hospital will help deliver many improvements
for patients. It will mean better access to
services and more joined up clinical care by
bringing together more services in the same
place”.
Health records centralisation is planned for and
aims to improve access to health records and to
reduce costs associated with off-site storage.
The Pathology service across the East of England
is under review with plans being overseen by
multi-agency representatives forming the
Transforming Pathology Partnership (TPP). TPP is
currently planned to go live in October 2013
although the exact date is not specifically under
Trust control.
Work will start on the chemotherapy service
expansion in the summer 2013. Such expansion
will facilitate the delivery of care to increasing
numbers of patients. The design team have
considered carefully the therapeutic environment
and have worked with the clinical teams to
maximise space availability for treatment,
out-patients and counselling. The provision of wi-fi
access will enable patients to bring in personal
electronic items to occupy themselves during
treatment. Space for the preparation of
chemotherapy has been increased and a
East and North Hertfordshire NHS Trust | Quality Account 2012/13
At the Lister Hospital building work has begun on
a new ward block which will accommodate 62
in-patients – 50% in single ensuite rooms.
Located adjacent to the new Emergency
Department and to the Hertfordshire Cardiac
Department the ward block will house the acute
assessment unit and the coronary care unit.
Work has also started on developing a new
theatre and endoscopy block which will be
completed in 2014 at which point the Lister will
become the main centre for inpatient and
emergency services for all of east and north
Hertfordshire, as well as parts of Bedfordshire.
65
The approval of the final business case enables
NHS Hertfordshire to complete its preparations
to build the New QEII hospital in Welwyn Garden
City. The new QEII will provide a wide range of
outpatient, diagnostic and ante/post natal
services, as well as Local A&E.
Further information on the new hospital is available via http://www.hertfordshire.nhs.uk/yourlocal-services/new-qeii.html
Sustainability
The Sustainability Development Strategy 2009-14
seeks to ensure the provision of high quality
healthcare today and into the future in a way that
minimises negative effects on the environment.
The aims of the strategy are implemented through
the Sustainable Development Management Plan
which outlines ten workstreams.
No
7
Workstream
Energy and Carbon Management – reduction of carbon emissions by 10% by 2015,
compared to 2007 levels
Procurement and Food
Low carbon travel, transport and access reduction of carbon emissions from staff
travel by 10% by 2015 compared to 2007
levels
Water consumption - reduction by 25% by
2020, relative to 2004/05 levels
Waste - reduction by 25% by 2020, relative
to 2004/05 levels; and increase recycling
figures to 75% by 2020
Designing the built environment to reduce
carbon emissions by 10% by 2015 and then
by 30% by 2020, relative to 2000 levels
Organisational and workforce development
8
Role of partnerships and networks
9
Governance
10
Finance
1
2
3
4
5
6
Progress against these workstreams is overseen
by the Sustainable Development Committee and
reported to the Finance and performance
Committee on a 6-monthly basis with an Annual
Report being sent to the Trust Board.
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3d Performance against national requirements
Compliance Framework
Priorities
Clostridium Difficile incidence
MRSA Bacteraemia
31-day second or subsequent
treatment (Surgery)*
31-day diagnosis to treatment
for all cancers*
31-day second or subsequent
treatment (Anti Cancer Drug
Treatments)*
31-day second or subsequent
treatment (Radiotherapy
Treatments)*
62-day urgent referral to
treatment of all cancers*
62-day referral to treatment
from screening*
18-week Referral to Treatment
(RTT) target for Admitted
pathways (95th percentile)*
18-week RTT target for NonAdmitted pathways (95th
percentile)
18-week RTT target for patients on incomplete pathways
(95th percentile)
All cancers: two week
maximum wait from GP
referral to first outpatient
Attendance*
2 week wait – Breast
Symptoms*
Four hour maximum wait in
A&E
82
55
11
13
Plan for
12/13
<=14
10
5
3
2
<=3
100%
99.32%
98.5%
97.6%
>=94%
98.93%
99.43%
99.3%
97.8%
>=96%
99.86%
99.83%
99.9%
99.8%
>=98%
97.95%
99.82%
99.4%
98.8%
>=94%
89.22%
88.79%
87.5%
86%
>=85%
95.29%
99.03%
95.7%
93.2%
>=90%
91.4%
92.4%
21.31
92.2%
>=90%
96.1%
97.3%
162
97.1%
>=95%
-
-
-
94.9%
>=92%
99.49%
99.19%
99.3 %
98.5%
>=93%
95.64%
96.73%
98.2%
96.3%
>=93%
98.6%
97.5%
95.9%
95.8%
>=95%
09/10
10/11
11/12
12/13
Met
1
The target in 2011/12 was <=23 weeks
The target in 2011/12 was <=18.3 weeks
* 1 month in arrears as reported at April 2013 Trust Board
2
Healthcare quality
indicators
Delayed transfers of care
Cancelled operations (%
of elective workload)
Cancelled operations
readmitted within 28 days
4.2%
2.5%
2.5%
2.8%
Plan for
12/13
<=3.5%
0.75%
0.68%
0.75%
0.58%
<=0.8%
99.44%
100%
100%
99%
100%
09/10
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10/11
11/12
12/13
Met
67
3e Statements from stakeholders
Overview
The Clinical Commissioning Group, Hertfordshire Healthwatch and Health Scrutiny Committee
(Hertfordshire County Council) are invited to comment on the draft report. Their responses are given
below.
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Trust response
The Trust acknowledges the difficulties faced by the Health Scrutiny Committee in producing a response
in line with recommendations. Whilst the Trust is disappointed with this outcome we have valued the
contribution of the Health Scrutiny Committee throughout the year on matters relating to the Quality
Account and other topics.
We look forward to working with the Health Scrutiny Committee for the foreseeable future.
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3f Statements from auditors
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Appendix 1 National Staff Survey 2012
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