Hinchingbrooke Health Care
NHS Trust
Quality Account
2012/2013
V 1.7
What is a Quality Account?
A Quality Account is an annual report produced by Hinchingbrooke Health Care NHS Trust. It aims
to give an overview of the quality of services provided by our organisation. The report can be used
by the public to make an informed choice about where they receive care and if they want to
choose our hospital.
What is Quality?
High-quality care is defined as:
safe;
having the right outcomes, including clinical outcomes (for example, do people get the
right treatment and are they well cared for?);
is a good experience for the people who use it, their carers and their families;
helping to prevent illness, and promoting healthy, independent living;
available to those who need it when they need it;
providing good value for money (Care Quality Commission, 2009).
Quality health care can be broken down into three areas:
patient safety;
patient experience;
clinical effectiveness.
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How to use this report
To make the report easier to use we have split it into sections
Part 1 – Contains an overview of quality.
Our Chief Executive is responsible for the quality of the services we provide and opens the report
with an overview of the work we have completed over the last year and the challenges we have set
ourselves for the coming year.
We work with our local patient groups and Commissioners to ensure we provide a quality service
tailored to our local population, they have provided independent statements on the quality of our
service which we have included.
With our partners Circle we have developed a new model of clinical leadership and set ourselves a
challenge to become a Top 10 District General Hospital. We have given a synopsis of our journey
thus far.
Part 2 – A look back on our quality performance.
We remain a NHS Trust and are accountable to the Department of Health, they have asked us to
complete mandated statements on quality. These statements appear in part 2 and can be used to
compare our performance against other NHS Trusts.
We look back on how we have performed against our quality targets set for 2012/2013 under the
three areas of quality:
patient safety;
patient experience;
clinical effectiveness.
We have included graphs and data wherever possible.
To assist readers we have included some additional information in the appendices.
Part 3 – Gives information on the quality of our services.
To improve quality at our Trust we use information from different internal sources such as audits,
research, and data quality.
Part 4 - Next year’s plans
We outline our priorities for improvement with the plans we have for 2013/2014, explaining why
we have chosen improvement areas and how we are driving momentum for change and
improvement within our organisation.
We have included definitions and additional information in the appendices to assist readers.
Thank you for taking the time to read our quality report.
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Contents
Part 1
An overview of quality ................................................................................................ 5
1.1
Opening by the Chief Executive ................................................................................ 5
1.2
What others say about us ........................................................................................ 7
1.3
What we have achieved in the last year ..................................................................... 9
1.4
Mandated statements on quality ............................................................................ 14
1.5
Care Quality Commission ....................................................................................... 16
Part 2
A look back on our quality performance 2012/2013 ..................................................... 17
2.1
How we monitor the quality of our services ............................................................. 17
2.2
Mandatory Quality outcomes ................................................................................. 18
2.3
Looking back on the quality of our services last year (2012/2013) ............................... 25
Patient safety ................................................................................................ 25
Patient experience goals 2012/13 .................................................................... 29
Clinical effectiveness goals 2012/2013 ............................................................. 34
Part 3
Work to support quality in our hospital ....................................................................... 37
3.1
Research ............................................................................................................. 37
3.2
Audit ................................................................................................................... 38
3.2.1 Audit Improvement .............................................................................................. 40
3.4
Information Governance ....................................................................................... 48
3.5
Our improvement goals for 2013/2014 ................................................................... 48
Summary and feedback ........................................................................................................... 51
Key to information boxes
Purple text boxes represent nationally mandated information
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Part 1
1.1
An overview of quality
Opening by the Chief Executive
It has been an exciting year for staff and patients; with our Circle colleagues we set ourselves an aim to
become a Top 10 District General Hospital providing excellent health care to the local population.
To achieve this aim we have changed the way we deliver health care. We have reorganised our staff and
placed them at the centre of patient care. It has been a year of huge change for both Hinchingbrooke and
the whole NHS.
At the end of the year we received the Francis report into the failings at Mid Staffordshire NHS Trust. It
painted a picture of the harm that can be caused when NHS Trusts get things wrong, betraying the trust that
the public place in us to care for their family and friends at times of great need. This gave us an opportunity
to pause and reflect on our own approach to quality, care and compassion. We have committed to ensure
we implement the lessons from the Francis report and will be providing information to the public via our
Trust Board.
The Quality Account is an opportunity to look back on our achievements and challenges over the last year
and present a clear picture to our community on where we have succeeded and where we must target
improvement. Our community deserve a local hospital that meets its needs and listens and responds to
feedback.
We have improved the quality of care in our hospital, this can be seen through the reduction in serious
incidents by 50% and that we have identified the true root causes and taken action that makes a difference.
Our process to protect patients from avoidable blood clots has worked extremely well and we are placed 4 th
in the East of England for VTE risk assessment.
Patients are at the centre of our improvement plans and we have worked hard to ask our patients how we
are doing. In 2012/2013, 83% of patients said they would recommend us. Many patients also told us where
we needed to improve, as a result we have a new menu, upgraded radiology department and fixed our roof.
We have also taken the step of publishing on our website what you say about us warts and all …. Here is a
taste of the latest comments;
“The only thing in past experience is the discharge sequence is extremely long”
“Quick, efficient service, service greatly improved in the last 5 years”
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The local community secured the future of Hinchingbrooke Hospital for 10 years under the Circle franchise.
We are committed to repaying our local community through a relentless pursuit of excellence. We remain
an NHS Trust providing NHS services. Our Circle partnership provides us with the energy and tools to
achieve our aim, the Circle credo sets out the passion in which we provide care and pursue excellence:
Our Purpose
To build a great company dedicated to our patients.
Our Parameters
We focus our efforts exclusively on:
What we are passionate about.
What we can become best at.
What drives our economic sustainability.
Our Principles
We are above all the agents of our patients. We aim to exceed their expectations every time so that we
earn their trust and loyalty. We strive to continuously improve the quality and the value of the care we give
our patients.
We empower our people to do their best. Our people are our greatest asset. We should select them
attentively and invest in them passionately. As everyone matters, everyone who contributes should be a
Partner in all that we do. In return, we expect them to give their patients all that they can.
We are unrelenting in the pursuit of excellence. We embrace innovation and learn from our mistakes. We
measure everything we do and we share the data with all to judge. Pursuing our ambition to be the best
healthcare provider is a never-ending process. 'Good enough' never is.
The information contained in the Quality Account is to the best of my knowledge an accurate account of the
quality of our services.
Mr Hisham Abdel-Rahman
Chief Executive
Hinchingbrooke Health Care NHS Trust
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1.2
What others say about us
We provide quality health care services to the people of Huntingdonshire and surrounding areas, a
population of approximately 167,300 people. In 2012/2013 our services were bought by NHS
Cambridgeshire, NHS Bedfordshire, NHS Peterborough and NHS Northamptonshire. NHS
Cambridgeshire purchased 95% of our services. In April 2013 the Primary Care Trusts changed to
become Local Commissioning Groups (LCG’s), the two main LCG’s are Hunts Health and Hunts Care
Partners. We work closely with them to review the quality and safety of the services we provide. They
have been involved in the production and development of our Quality Account and suggested
changes that can be found in appendix 1.
Cambridgeshire and Peterborough Clinical Commissioning Group (the CCG) has reviewed the
Quality Account produced by Hinchingbrooke Health Care NHS Trust (HHCT) for 2012/13.
The CCG and HHCT work closely together to review performance against quality indicators and
ensure any concerns are addressed. There is a structure of regular meetings in place between the
CCG, HHCT and other appropriate stakeholders to ensure the quality of HHCT services is reviewed
continuously with the commissioner throughout the year. In addition, the CCG has carried out
announced and unannounced visits to HHCT to observe practice and talk to staff and patients about
quality of care, feeding back any concerns and actions required by the Trust.
Following a series of Serious Incidents in Colorectal care at HHCT, complex surgical cases were
suspended in this service during 2011/12. The Trust addressed all the issues of concern and
achieved the required improvements during 2012 and the CCG agreed that services can be
reinstated in January 2013. HHCT has established robust monitoring systems and the CCG will
maintain close scrutiny on the outcomes of the service.
The CCG has concerns about the increase in Healthcare Acquired Infections in HHCT in 2012/13.
The Trust exceeded its Clostridium Difficile ceiling of seven and the CCG worked with the Trust to
ensure multidisciplinary reviews of all cases took place so that poor practice was addressed by
actions likely to have a positive impact in reducing incidence.
The Care Quality Commission (CQC) is the national regulator of quality in the NHS and carries out
inspections across all health and social care organisations. The CQC inspected HHCT in August 2012
and had no concerns about compliance with the outcomes reviewed. The minor concern in relation
to safety, availability and suitability of equipment reported in September 2011 was removed by the
CQC in November 2012 and the Trust currently has no CQC concerns. Details of the CQC concerns
are given in the Quality Account.
The NHS Safety Thermometer provides a quick and simple method for surveying patient harms and
analysing results so that trusts can measure and monitor local improvement and harm free care
over time. Trusts collected data on four harms throughout 2012/13; Pressure Ulcers, Falls, Urinary
Infections (in patients with catheters) and venous thomboembolism (VTE) prevention. HHCT had
one of the lower harm free care percentages in the local area with a rate below 90% for six months
of the year. The Trust reviews all areas of harm free care monthly and has action plans in place to
drive improvement. However, there is limited detail in the Quality Account of the different
elements of the Safety Thermometer and performance against 2012/13 goals. The CCG expect the
Trust to continue the focus on improving harm free care as a priority for 2013/14.
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The Trust is managed by a private provider, Circle, but remains in the NHS. The Quality Account sets
out some of the innovative approaches used by the hospital to drive improvements in care.
Improving staff engagement is a Trust priority as the national staff survey results in this area are
below average, The Compassionate Care Celebration Event was an opportunity to celebrate success
and say thank you to staff. Staff have also been encouraged to play a vital part in the safety culture
of the Trust, with the Stop the Line initiative set out in the Quality Account. Although it is not one of
the Trust’s priorities for 2013/14, the CCG expect the initiatives for improving staff engagement to
be taken forward in the future.
Improvement in patient experience remains a priority for the HHCT. The results in the national
inpatient survey were better than most other trusts for overall views and experience, and similar to
other trusts in the other areas surveyed, with some clear themes for improvement identified in the
survey. The Trust has a programme of local patient surveys and the CCG would like to see further
analysis of issues identified where patient feedback highlights areas for improvement. HHCT uses
the Net Promoter / Friends and Family question as part of their patient experience surveys. The
question asks ‘Would you recommend the trust to family and friends?’ HHCT have achieved very
good ‘Friends and Family’ rates for the majority of 2012/13.
The Quality Account gives details of the Commissioning for Quality and Innovation (CQUIN) scheme,
which rewards trusts for developing and implementing innovative plans for improvement. HHCT
have achieved improvements across a range of initiatives. However, there remains a problem with
the timeliness of providing discharge summaries to GPs, and the CCG expect a robust system to be
put in place promptly, while a longer-term IT solution is in development.
There is a significant focus in the Quality Account on the initiatives that have led to improvement
with less emphasis on priorities for future development where further work is needed. The Quality
Account is presented in an understandable and consistent format, and explains the context of the
document. A clear explanation of any clinical issues is given and jargon is avoided in the majority of
the report. The report includes all the nationally mandated sections.
We work hard to involve the people who use our services, seeking to find out their opinions and
priorities for improvement. We meet every two months with our Local Improvement Network (LINk)
to discuss concerns and seek ideas and patient involvement. In April 2013 LINk were superseded by
Healthwatch. We asked Healthwatch to review our Quality Account; they have declined to comment
this year due to their recent formation. Their response is quoted below:
“Healthwatch Cambridgeshire are still in the early days of start-up and this year we will not be
commenting on any of the annual Quality Accounts, however, they are of much interest and I will
share them with the rest of the team”. Kate Hales - Co-ordinator -Healthwatch Cambridgeshire
As we are a NHS Trust funded by the tax payer we are accountable to public bodies. The Health
Overview and Scrutiny Committee in Huntingdonshire monitor our services; they have provided the
following statement:
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"As a result of the County Council elections, the Council's Committees were not determined
at the time that comments on the draft quality account were required. We are therefore not
able to provide a full Overview and Scrutiny Committee response on this occasion.
The Committee considered the Trusts business plan in early 2012. It welcomed and
supported the Trusts improvement goals for 2012/13, and its ambitions to become one of
the top ten district hospitals in England. The Committee examined progress against these
goals, and the Trust’s financial position and plans, in February 2013, and welcomed the
quality improvements that have been made.
As part of a county-wide scrutiny review of delayed discharge, the Committee examined the
work being done by the Trust to improve discharge planning and patient flows at
Hinchingbrooke, and has made recommendations to the Trust in relation to the discharge
process. This links to the commitment in the Quality Account to improve the timeliness of
discharge planning summaries to GPs.
In relation to patient experience, committee members highlighted to the Trust the
importance of ensuring timely communication with patients and their relatives when they
make a complaint or raise a concern. “
1.3
What we have achieved in the last year
Over the last year we have asked our staff to commit to putting Patients First, the following section
gives an overview of our activities.
Compassionate Care
Our Compassionate Care Celebration Event brought together staff from all areas of the hospital to
celebrate the outstanding service we provide to patients and reward those who have gone the extra
mile to improve patient care.
Lorraine Szeremeta Deputy Director of Nursing, organised the campaign and the event and believes
that: “Compassionate Care is not a new philosophy for Hinchingbrooke staff, but the campaign has
given us an excellent chance to refocus our priorities and to celebrate the good work that we are all
already doing. Compassionate Care is all about treating patients as individuals and remembering to
approach the patient as a whole person and to look further than just their illness or condition. We’re
lucky enough to have some outstanding staff here at the
hospital, and this event was our chance to say thank you.”
Compassionate Care is not just for clinical staff either – we all
have a part to play, and during the campaign, over 500 staff
from all areas of the hospital came together to pledge their
commitment and give their ‘thumbs up’ to putting patients
first.
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The Diabetes Nursing Team were Highly Commended in the awards ceremony for Companionate Care
and Linda Kelly, our Diabetes Inpatient Specialist Nurse explains why the event inspired her to take a
fresh look at compassion.
“I am a member of the Diabetes Nursing Team and my work mostly
involves the care of inpatients. We were thrilled to receive one of the
'Highly Commended' team awards.
We knew little about the
Compassionate Care campaign, other than seeing the Christmas tree
at the front of the of the hospital and I am ashamed to say that I was
one of those cynical beings who thought 'Do nurses really need to be
taught how to give compassionate care?! ' I knew that I was not alone
in this feeling as other members of staff had said the same. We were summoned to the event a little
reluctantly as we were so busy and it was going to take a big chunk out of our day.”
“I’m very glad I did attend though as wow, it was a wonderful event and not just because we had won
an award. It is very difficult to put into words the feeling that was in that room. The Director of
Nursing’s excellent talk was given from the heart and resonated with me instantly. She said: ‘there
are things that get in the way of compassionate care' and although she was not explicit in what
'things’ I knew and I guess everyone else did too: short staffed, bed management, 4 hour waits, short
stay beds etc the list goes on…”
“There was not a dry eye in the room following the praise from a dear, elderly gentleman for the care
his late wife received during her last days on Apple Tree Ward. This was endorsed by his daughter and
was heart-warming.”
“Some of our staff were recognised for the work they have
carried out to put their ‘Patient 1st' it was great to see this.
We do not celebrate our successes enough. Then, having
watched a powerfully emotive DVD followed by Scott’s
service and the anointing of our palms with oil – a symbolic
gesture of our commitment to Compassionate Care, I was
overwhelmed with emotion. To include the service at a time
when 'religion' is considered by many to be out of fashion
and attendances at church low, this was a courageous thing
to do. But it worked!”
“I am not 'religious’ in the true sense as I do not attend church.
I do believe that our aim in life should be to treat everyone and
everything with dignity and respect, love our families and
friends unselfishly, treasure all that we have and live a 'good
life'. Scott has said to me, his 'church' is in this hospital (I hope
he does not mind me quoting him) and that some of his most
spiritual moments have been under this roof.”
“Although I consider myself a compassionate nurse, thanks to
this event I have taken a fresh look at 'compassion' but also
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will, as all of us must, put the patient first whatever the pressures may be for us not to do so. This
may make us unpopular at times but no-one can reprimand us for giving Compassionate Care and
putting the ‘Patient 1st’!”
Community Partnerships
As well as caring with compassion we have tried to help reduce the need for nursing beds over
winter. In November 2012 we worked with NHS Cambridgeshire to open a temporary Community
Transition Unit (CTU) at the hospital. This nurse-led unit looked after patients who are medically fit
for discharge but who are waiting for an alternative form of care within the community. The unit
enables nursing staff to concentrate on getting patients ready for their return to the community. The
development of this unit and redesign of the service was conducted with public involvement.
Staff are our biggest assets at Hinchingbrooke:
A total of 63% of our staff responded to the 2012 staff survey which is in the highest 20% of Acute
Trusts in England. We have summarised the key results below, both nationally and locally. The survey
covers areas including quality of care, job satisfaction, appraisals, line management, and health and
wellbeing. There are 28 key findings within the survey plus an overall staff engagement score.
Compared with the 2011 findings, we saw improvements in the results for team working and job
satisfaction as well as an increase in the number of staff being appraised. We also saw a decrease in
the number of staff reporting discrimination in the workplace.
The not so good news was that our overall staff engagement figure had improved marginally; it’s still
below average when compared to similar Acute Trusts so we have more work to do here.
Improving staff engagement is one of our top
priorities, and it’s an area where there’s definitely
room for improvement. Jenny Williams has been
appointed as Head of Communications and
Engagement, to put some much needed emphasis on
staff engagement. The team will be working hard to
ensure that we introduce more face to face
interaction between staff and our senior team, that
there are more opportunities for staff to be involved
in the decision making on issues and improvements
in their areas and that they are kept informed about
all of the news that matters.
Small is strong -top of the tables for A&E
In January 2013 we achieved number one spot in the country for the 4 hour wait target, overall in the
year we were rated as having the 8th best 4 hour wait nationally.
We achieved this through a Trust-wide approach to managing capacity and discharges to ensure that
we maintain patient flow and that beds are readily available so that our patients do not spend
protracted amounts of time in the Emergency Department (ED). This has involved changes in practice
from our site managers, lead nurses and ward teams. By 1pm each day we identify the patients who
will be going home tomorrow and work together to ensure that everything is in place for a smooth
discharge.
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In addition, we opened our short stay unit and have been working closely with our partners from
community services to ensure that there are sufficient care packages and interim beds available in
the community and Community Transition Unit.
Over recent months we have invested heavily in the development of the ED, Acute Assessment Unit
(AAU and Short Stay Unit (SSU) teams to up skill everyone and empower our shift leaders to escalate
anything that may affect patient flow or our patients receiving timely care. This can vary from a delay
in a senior review from a specialist team, to delays in transport, to challenges with the high numbers
of patients in the department. We have also introduced the 3333 escalation bleep to ensure that
24/7 there is a single point of contact for a senior member of staff to support the teams in our Clinical
Units.
As well as the 4 hour target for ED which gives us 4 hours to discharge or
admit a patient, we have worked tirelessly to achieve our other indicators
such as the taken time to see a doctor where our average is under 1 hour,
re-attendance and left without being seen rates all of which exceed the
national standards. We have also been working to improve our times for
triage/initial assessment where our 95th percentile performance is at 17
minutes against a target of under 15 minutes – this is already a real
improvement from earlier in the year. Only patients with very minor conditions now wait in excess of
15 minutes for initial assessment.
We are incredibly proud of this brilliant achievement, it reflects the tremendous efforts made by a
huge group of staff from all areas of the hospital and it shows the difference that team work can
make. This time last year we were struggling with performance and received an improvement notice
from our commissioners as a result. It’s great to be able to now say that we are the best in the
country.
Colorectal service up and running
Concerns were raised over the quality of the colorectal service at the Trust in June 2011 following a
number of high profile inquests. The Trust immediately suspended the aspects of the service
concerned, and invited the Royal College of Surgeons (RCS) to independently review the service. The
RCS report highlighted a number of serious failings within the colorectal service, particularly around
systems and processes. The Trust accepted these findings, and put in place a programme of intensive
support to improve the quality of the service.
A leading colorectal surgeon from Circle’s Nottingham Treatment Centre was employed one day a
week to review all aspects of the service and continues to provide on-going support. Two additional
surgeons have been recruited as well as the specialist nurse hours. This strengthens the department
and reduces reliance on locums.
The RCS independent review was supplemented by an external nursing review which looked into
colorectal nursing and wider nursing processes. Mr Hisham Abdel-Rahman, Medical Director for
Hinchingbrooke Health Care NHS Trust apologised to the public and has overseen the implementation
of the recommendations. After a period of sustained work to improve the service, major colorectal
surgery was re-started in January 2013, with the approval of the Commissioners. The RCS will be
visiting the Trust in the summer months and the outcomes of this visit will be made available to the
public via the Trust Board.
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Stop the Line
Stop the Line is the name of our patient safety system that we introduced in June 2012. The system
has two main elements the management of serious incidents focusing on rapid response and learning
and the culture of safety in our Trust.
The beliefs behind Stop the Line are that ‘safety events can be
prevented’ and ‘our staff know when we have a problem’. We aim to
create a culture where staff can speak up to prevent harm.
In May 2012 we trained 40 Stop the Line Champions to take this
message out to the organisation; we got staff and public talking about
the idea behind Stop the Line through innovative events and ideas such
as:
Wrapping the corridors in red ribbon and posters;
Challenging the champions to get staff to sign up to the system;
Wear red to work day;
Best photo for Stop the Line.
The noise paid off with 1000 members of staff pledging to Stop the Line, one of our porters was seen
explaining to some visitors what the red ribbon meant in relation to our safety aims and the Contact
Centre won the best photo award. These few examples show how the whole hospital got behind one
shared idea and goal.
Our staff that pledged to stop and act for safety and they have delivered on this promise. A number
of ‘Stop the Line’ calls have been made and as a result our patients are safer.
In June 2012 our theatre team could not find a swab and were concerned that they needed to end
the operation. The team called a ‘Stop the Line’ and decided to get fresh eyes in the room. As a result
they repositioned the patient and took an x-ray of a different part of the patient’s abdomen. This
identified the swab and the patient was saved a needless second operation.
The Endoscopy unit perform procedures using cameras, they called a ‘Stop the Line’ when some
equipment test results came back as having failed. They worked hard to maintain safety and found a
solution to the equipment failure and only one patient list was cancelled.
In the theatre preparation room the support staff recognised
that a sterile cover for equipment was ripped. They called a
‘Stop the Line’ and decided that the cover was not durable
enough within days a new stronger cover was found for all
trays and at a lower cost!
Our leadership have signed a pledge to support staff who
raise a concern (even if they are wrong) and teams have been
empowered to act immediately to rectify problems and
prevent harm. We have made major progress in creating a
culture of openness, learning and continuous improvement. We will continue to use Stop the Line to
improve our safety culture and deliver a responsive safe hospital for our patients.
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Medical Revalidation
It is the process by which all doctors with a licence to practise in the UK are required to satisfy the
General Medical Council (GMC) each 5 years that they are maintaining high professional standards
and should retain their licence. The evidence is collected through mandatory, comprehensive annual
appraisal and at least 5 yearly patient and colleague feedback questionnaires.
Medical revalidation was formally launched by the GMC on 3 December 2012.
It is the process by which all doctors with a licence to practice in the UK are
required to satisfy the General Medical Council (GMC) each 5 years that they
are maintaining high professional standards and should retain their licence.
The evidence is collected through mandatory, comprehensive annual appraisal
and at least 5 yearly patient and colleague feedback questionnaires.
Revalidation helps to assure that the doctors practising in our organisation are
up to date and fit to practise. We have a robust system of appraisal and clinical
governance that supports our doctors with revalidation. Dr Catherine Hubbard
is our organisation’s responsible officer and has a statutory duty to make sure the information that
underpins revalidation is in place.
1.4
Mandated statements on quality
All NHS Trusts must include mandated statements on the quality of services that they provide. These
statements are in the same format for each Trust and help the public make comparisons between
providers. The following section contains our statements in relation to quality.
During 2012/2013 Hinchingbrooke Health Care NHS Trust provided and sub-contracted 42 NHS
services. The Trust has reviewed all the data available to them on the quality of care in 41 of these
NHS services. Areas identified for improvement from the review of this data are included in our
Improvement Goals for 2013/2014 in section 3.5. The income generated by the NHS services
reviewed in 2012/2013 represents 99% per cent of the total income generated from the provision
of NHS services by the Trust for 2012/2013.
We have worked hard to achieve our CQUIN targets for 2012/2013. We failed to achieve only one
goal, our CQUIN on timeliness of discharge summaries. We recognise that our community colleagues
require timely information on the treatment of patients whilst in hospital and want to explore ways in
which IT systems can communicate enabling our GP colleagues to view hospital information.
A proportion of Hinchingbrooke Health Care NHS Trust’s income in 2012/2013 was conditional on
achieving quality improvement and innovation goals agreed between NHS Cambridgeshire for the
provision of NHS services, through the Commissioning for Quality and Innovation Payment
Framework. Further details of the agreed goals for 2012/2013 can be found at
http://www.hinchingbrooke.nhs.uk/page/about-us/trust-publications/cquin. 2013/2014 CQUIN
target is listed below.
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CQUIN
5.1 Older & Vulnerable:
Community Geriatrician
Milestone description
Propose and agree a job specification for the community geriatrician
post
6.2 End of life: Share my care
Agree baseline for number of patients expected to be on share my
care trajectory to achieve 15% roll out of plans in place
6.1 End of Life: Amber care
bundle
Agree trajectory to achieve 100% coverage for all wards with Amber
care bundle
7.1 7 day working:
Diagnostics
Agree baseline, implementation plan and roll out trajectory to
improve access to non-urgent diagnostic services for inpatients 7
days per week
Submission of proposed ceiling of care packages for each type of
patient being admitted to a care/residential home
Agree trajectory to achieve 95% coverage of patients
5.2 Older & Vulnerable:
Ceiling of Care
5.2 Older & Vulnerable:
Ceiling of Care
5.3 Older and Vulnerable:
Management plans
5.3 Older and Vulnerable:
Management plans
5.1 Older & Vulnerable:
Community Geriatrician
5.2 Older & Vulnerable:
Ceiling of Care
5.3 Older and Vulnerable:
Management plans
5.3 Older and Vulnerable:
Management plans
6.1 End of Life: Amber care
bundle
6.1 End of Life: Amber care
bundle
6.1 End of Life: Amber care
bundle
7.1 7 day working:
Diagnostics
7.1 7 day working:
Diagnostics
5.1 Older & Vulnerable:
Community Geriatrician
5.2 Older & Vulnerable:
Ceiling of Care
6.2 End of life: Share my care
6.2 End of life: Share my care
6.2 End of life: Share my care
5.3 Older and Vulnerable:
Management plans
Agree the content of personal management plans that will be shared
with Carers and the patient GP
Agree trajectory to achieve 95% provision of personal management
plans to patients
Metric reduction in number of non-elective admissions >75 years old
Metric reduction in number of non-elective admissions >75 years old
Achieve 70% provision of personal management care plans to
patients in line with trajectory
Achieve 80% provision of personal management care plans to
patients in line with trajectory
Achieve 50% of wards covered by Amber care bundle in line with
trajectory
Achieve 75% of wards covered by Amber care bundle in line with
trajectory
Achieve 100% of wards covered by Amber care bundle in line with
trajectory
Achievement of timeline within 12 hours measure in line with
trajectory
Achievement of access to non-urgent Diagnostics on Sat/Sun in line
with trajectory
Community Geriatrician provision by 1st Sep 2013
Achievement of 95% coverage of care/residential home patients by
ceiling of care packages
Achieve 5% of expected patients on share my care have a plan
Achieve 10% of expected patients on share my care have a plan
Achieve 15% of expected patients on share my care have a plan
Achievement of 95% provision of personal management care plans to
patients
- 15 -
6.1 End of Life: Amber care
bundle
6.2 End of life: Share my care
7.1 7 day working:
Diagnostics
1.5
Achieve 10% increase in the number of patients dying in their place
of choice by outcome measure
Achieve 10% increase in the number of patients dying in their place
of choice by outcome measure
Achieve 10% reduction in the average time taken from referral to
delivery of diagnostic test
Care Quality Commission
We have a duty to provide health care services in line with the essential standards of care laid out by
the Care Quality Commission (CQC). The following statement sets out our registration status.
Hinchingbrooke Health Care NHS Trust is required to register with the CQC and our current
registration status is registered without conditions or concerns. Hinchingbrooke Health Care NHS
Trust is registered to provide the following services:
Treatment for disease, disorder or injury;
Assessment or medical treatment of persons detained under the Mental Health Act;
Surgical procedures;
Diagnostic and screening procedures;
Maternity and midwifery services;
Termination of pregnancy;
Family planning.
The Care Quality Commission visited our site on the 12th August 2012 and completed a nationally
themed Dignity and Nutrition Inspection (DANI) on:
Outcome 1 – Privacy & Dignity and involvement of people in their care;
Outcome 5 – Nutrition;
Outcome 7 – Safeguarding;
Outcome 13 – Staffing;
Outcome 21 – Record Keeping.
The CQC also conducted a desktop review on the 4th December 2012 for Outcome 11 – Safety and
Suitability of Equipment. Our service was found to be fully compliant with the outcomes assessed
and we are currently registered without conditions.
- 16 -
Part 2
2.1
A look back on our quality performance 2012/2013
How we monitor the quality of our services
In February 2012 we worked with our partners Circle to implement a new approach to assuring and
improving the quality of our services. The idea was simple, put doctors and nurse leaders closer to
their patients and enable them to manage the quality of the service they deliver. The diagram below
illustrates this structure.
- 17 -
Our services were organised into 13 Clinical Units each one lead by a doctor, nurse and manager.
They meet weekly to monitor and discuss improvements for the service they provide. Every month
they review the quality of their service and discuss complaints, incidents, NICE guidance, audit, alerts,
PALS and patient feedback to inform them of areas that require action. They are supported through
this process by the Quality and Risk Management department. Once a month the Clinical Unit Leads
come together at a meeting called Clinical Governance and Risk Management Committee (CGRM) to
discuss issues of concern and share best practice, this committee report to the Executive Board who
in turn provide information to the Trust Board.
2.2
Mandatory Quality outcomes
The NHS Medical Director Professor Sir Bruce Keogh has mandated that we report against a small
core set of quality indicators in our Quality Account. This enables the general public to compare NHS
Trusts and help us to identify areas where we must improve.
Mortality:
Summary Hospital Level Mortality Indicator (SHMI) is a way of monitoring hospital mortality rates. It
is a risk adjusted ratio of deaths associated with hospital admission that enables hospital rates to be
compared.
- 18 -
The colour of the bars in the graph above is as follows; Red – Statistically high mortality, Blue –
normal mortality, Green – Statistically low mortality.
Due to the speed of availability of national data there is a delay of several months in receiving this
information. Our current data is for October 2011 – September 2012; we have a SHMI of 94.2 the
national benchmark is 100. This is normal mortality rate.
HHCT SHMI
July 2011 to June October 2011
September 2012
2012
94.1
93.9
to
Hinchingbrooke Health Care NHS Trust considers the SHMI data is as described, as the calculation
is made on data that has been subject to internal quality assurance. Each patient who passes away
has codes attached to their care episode; this is verified by the consultant prior to data
submission. Hinchingbrooke believe that improvements in care can be made when reviewing
patient’s episodes of care and will aim to improve the care of patients and reduce mortality
through strengthening the mortality review process in the forthcoming year.
Every month we track crude mortality as an early indicator of increasing mortality the graph below
shows 2012/2013 numbers. In May 2012 we saw an increase in crude mortality and our Medical
Director reviewed 10% of the cases and found no concerns this was normal variation.
We assign a code to each patient for their diagnosis on admission and discharge, this process enables
us to see what conditions we are treating.
National
Hinchingbrooke
Nationally the percentage of patient admissions with
1.0%,
1.6%.
palliative care coded at either diagnosis or specialty level is
approximately
Nationally the percentage of patient deaths with palliative
18.9%,
27.5
care coded at either diagnosis or specialty level is
approximately
The palliative care coding rates are an indicator of the patient population we treat.
- 19 -
PROMS
Hinchingbrooke Health Care NHS Trust considers the PROMS data is as described, as the
calculation is made on data that has been returned from patients. Each patient’s questionnaire is
securely stored. Hinchingbrooke believe that improvement’s in patients outcomes can be made
through careful review of each procedure ensuring standardisation of treatment, information and
counselling to patients. In the next year individual consultants will be enable to review their
PROMs outcomes and seek to improve where required.
We ask patients how they are before and following their procedures for:
Hip replacement (HR);
Knee replacement (KR;)
Groin Hernia (GH);
Varicose Veins (VV).
The number of patients that participate is benchmarked nationally.
You can see from the graph above that we have made huge improvements in all four procedures.
The questionnaire also asks if patients have had improvements in quality of life (EQ-5D) and pain (EQ
VAS) the comparative results are shown below.
2011/2012
HR
KR
GH
VV
HHCT
Q1 EQ- Q1 EQ
5D
VAS
Health
Profile
94.3%
92.1%
94.0%
92.2%
99.0%
92.9%
97.4%
94.7%
2012/2013
National
Q1 EQ- Q1 EQ
5D
VAS
Health
Profile
93.7%
90.4%
93.1%
89.5%
96.2%
92.5%
94.5%
91.1%
- 20 -
HHCT
Q1 EQ- Q1 EQ
5D
VAS
Health
Profile
92.8%
93.1%
95.0%
90.1%
95.7%
98.2%
100.0%
92.0%
National
Q1 EQ- Q1 EQ
5D
VAS
Health
Profile
93.2%
89.3%
92.6%
88.2%
96.0%
94.8%
94.6%
92.7%
Overall our patients are experiencing good outcomes from their surgery in line with national
performance. In 2012-2013 green indicates better than national and amber slightly below national.
Emergency readmissions to hospital within 28 days of discharge
Hinchingbrooke Health Care NHS Trust considers the readmission data is as described, as the
calculation is made on data that has been subject to internal quality assurance. Each patient who
is admitted has a code attached to their care episode, and this is submitted by the information
department. Hinchingbrooke believe that readmissions can be reduced to the lowest possible
number by working with community providers to integrate care from primary to secondary care.
0 – 14 years
Rate via Dr Foster April – December 2012
(readmission to all hospitals)
Hinchingbrooke
1.4%
East of England
5.1%
15 years and over
Rate via Dr Foster April – December 2012
(readmission to all hospitals)
Hinchingbrooke
5.3%
East of England
5.9%
0 – 14 years
Hinchingbrooke internal data April 2012 –
March 2013 (full year) not yet nationally
benchmarkable (readmission to Hinchingbrooke
Hospital)
Hinchingbrooke
1.45%
East of England
Data not yet
available.
15 years and over
Hinchingbrooke internal data April 2012 –
March 2013 (full year) not yet nationally
benchmarkable (readmission to Hinchingbrooke
Hospital)
Hinchingbrooke
4.49%
East of England
Data not yet
available.
The top two tables above illustrate external data from Dr Foster which confirms the readmission rates
at Hinchingbrooke to be below the East of England average for the period April – December 2012.
(The full year data was not available at the time of writing).
The bottom two tables above illustrate the Hinchingbrooke only rate for full year 2012/2013. This is
not benchmarkable with external data as this data was not available at the time of writing.
- 21 -
Trusts responsiveness to inpatients’ personal needs
Hinchingbrooke Health Care NHS Trust considers the inpatient survey data to be as described
because the questionnaire is administered by a 3rd party and the data sample is random.
Hinchingbrooke believe that improvements in care can be made and have a program of work to
put Patients First and release more nursing time so patients feel fully supported whilst in hospital.
Every year we participate in a national inpatient survey, a number of questions are asked, one of
which is our responsiveness to inpatient needs.
2011
70.2%
Responsiveness to inpatient needs
2012
68.1%
Although performance is marginally less than 2011 it remained above the national average of 67.4 %
Percentage of staff who would recommend the Trust as a provider of care for friends and
family.
Hinchingbrooke Health Care NHS Trust considers the staff survey data to be as described because
the questionnaire is administered by a 3rd party, this year all staff were sent a questionnaire to
improve data integrity. Hinchingbrooke believe that improvements in staff engagement can be
made and have a plan of work to become a great place to work focusing on eight key areas:
leadership;
fair deal;
my manager;
personal growth;
wellbeing;
my company;
my team;
giving something back.
The results for the staff survey on ‘would staff recommend the Trust as a provider for friends and
family’ has deteriorated, our staff engagement work is focused on making significant improvements
in the next 12 months. The table and graph below show the change in scores from 2011 to 2012 and
shows that Hinchingbrooke was below the national average.
2011
3.55
Recommend the Trust as a provider of
care for friends and family.
- 22 -
2012
3.46
Percentage of admitted patients risk-assessed for Venous Thromboembolism
Hinchingbrooke Health Care NHS Trust considers the VTE data is as described, as the information
is collected by census and in 2011/2012 it was confirmed accurate by our own VTE Nurse quality
audit. Hinchingbrooke believe that a small improvement in VTE assessment can be made and are
striving towards 100% assessment rates.
The VTE assessment data for quarter 3
2012/12 (October to December 2012)
Hinchingbrooke
99.5%
National
94.2%.
Our achievements in relation to VTE are described in full in the Patient safety section.
Rate of C. difficile per 100,000 bed days
Hinchingbrooke Health Care NHS Trust considers the C.diff data is as described, as the data has
been confirmed by our own Infection Prevention and Control Team audit. Hinchingbrooke believe
that a small improvement’s in the rates of C.diff can be made through improved adherence to
antibiotic prescribing and infection control procedures.
C.difficile Infection counts and rates in
patients aged 2 years and over 2012/2013
Hinchingbrooke
National
11.55
28.25
Although our rates are lower than the national average, we failed to meet our own locally agreed
target and we are concentrating on improving this further in 2013/2014.
- 23 -
Rate of patient safety incidents and percentage resulting in severe harm or death
Hinchingbrooke Health Care NHS Trust considers the incident data is as described, as the process
has been subject to internal audit. Each incident with an impact of severe harm of death is
uploaded to the NRLS who publish the data. Hinchingbrooke believe that improvements in the
number of serious incidents can be made through the monitoring and implementation of serious
incident action plans.
We use incident reporting to ensure we learn lessons from patient safety events. Each incident form
is given a grading dependent on the harm caused to patients; no harm, low harm, moderate harm,
severe harm or death. All our patient safety incidents are shared with the Department of Health to
ensure other providers can learn lessons from our incidents. Nationally we are able to compare our
incident rate.
Current data is available for 1st April 2012 to 30th September 2012 where we are in the middle 50% of
reporters which shows a good reporting culture. The rate of patient safety incidents reported was
5.93 per 100 admissions.
The table below shows how we compare nationally.
Nationally the percentage of severe harm incidents we
reported was
Nationally the rates of death incidents we reported was
Hinchingbrooke
0.7%
National
0.7%
0.1%.
0.2%
We are aiming to increase the amount of investigation and feedback we conduct on incident reports
and have included these plans in our Stop the Line activities in 2013/2014.
The table below gives the Trusts own information on the number of incidents reported over the last
two financial years by level of harm. There is a significant reduction in severe harm and death.
Actual Impact
Death
Severe Harm (SIRI)
Moderate Harm
Low Minimal Harm
Incident Occurred No Harm
Near Miss Incident Prevented
2011/2012 2012/2013
8
2
28
15
50
50
955
905
2777
2538
606
380
As an NHS provider we aim to provide safe high quality care, sadly at times we make mistakes and
harm those we should be caring for. When a patient suffers severe harm we report a serious incident
and conduct a thorough investigation called a Root Cause Analysis (RCA). The majority of the harm
events investigated as serious incidents relate to patients falling or developing pressure ulcers in our
care. We are sorry that patients and families have suffered as a result of harm and are committed to
- 24 -
reduce the number of avoidable incidents and implement all the lessons from our investigations to
safeguard future service users.
2.3
Looking back on the quality of our services last year (2012/2013)
In our 2010/2011 Quality Account we set ourselves areas for quality improvement across the 3
aspects of quality (Patient Safety, Patient Experience and Clinical Effectiveness). The following
section of the report outlines our success and challenges in achieving these targets. Where we can,
we have included data and explanations about the target.
Patient safety
We aim to deliver high levels of patient safety and satisfaction. We count any harm to a patient as
one too many and want to provide the safest care possible. Our goals were to:
Implement the NHS Safety Thermometer and reduce the harm events to patients
The aim of the Safety Thermometer project is to improve collection of data in relation to pressure
ulcers, falls, urinary tract infection in patients with a catheter, and VTE assessment. We measure this
monthly surveying all inpatients on one set day.
The graph above shows our journey over the last 12 months. The percentage relates to harm free
care and over the year this improved from 87% to 93%. Data relating to other NHS Trusts is not
available so cannot be used to benchmark performance. We are committed to ensuring the safety of
our patients and aim to eliminate all grade 3 and 4 hospital acquired pressure ulcers in the coming
year.
- 25 -
Improving the quality of our documentation
We recognised through complaints, audits and incident investigation that the standard and
completeness of our documentation could be improved. We listened to staff and streamlined our
inpatient documentation, the current care episode was amalgamated into one file that all MDT
members wrote in. We audited the effectiveness of this change; a summary of the results is below.
Aspect measured
Items duplicated
Blank records in patient's admission
Poor quality copies of documentation
Notes not written sequentially
Non HHCT ratified documentation
Target
0%
0%
0%
0%
0%
%
Achieved
March
2013
0%
48%
68%
0%
20%
%
Achieved
June 2012
56%
96%
84%
12%
18%
No
Achieved
March
2013
0/50
24/50
34/50
0/50
10/50
No
Achieved
June 2012
28/50
48/50
42/50
06/50
9/50
In June 2012 an audit looked into the quality of the documentation, this audit was repeated after the
change in March 2013 and significant improvements were made. In 2013/2014 we want to continue
this good work by providing more advice to staff and spend more time on reducing unnecessary
documentation. This will help to reduce bureaucracy and give nurses and doctors the time they need
to spend with their patients.
VTE assessment
We wanted to become a highly reliable organisation in relation to VTE assessment, all our patients
must be protected against blood clots by having an assessment of their risk factors. We aimed to
build on our success from last year and become a leading hospital in VTE assessment rates.
- 26 -
In April 2012 we were set a national target of 98% VTE assessment rate the graph, above shows that
we achieved this target in 2012/2013 and October achieved 100% assessment rate. This put us 4 th in
the East of England for VTE risk assessment and 8th nationally! We aim to continue this level of
assessment and key to this is educating our Junior Doctor workforce who, as part of their training,
move around the hospitals in the east region every 4 months.
Serious incident rate and learning
In June 2012 we introduced and embedded our own ‘Stop the Line’ process for the identification,
reporting, investigation and lesson learning from serious incidents. Integral to this aim was the launch
of ‘Stop the Line’ as a way to improve the safety culture with in our hospital. We ran a month long
campaign with our staff placing responsibility on them to speak up for safety. Staff often know when
something is not safe and by using ‘Stop the Line’ they can act with their team members to stop a
process and find solutions to make it safer.
As a result of all the hospital staffs hard work we have seen over a 50% reduction in serious incidents
in 2012/2013 as seen in the graph below.
In the staff survey we asked ‘When errors, near misses or incidents are reported my organisation
takes action to ensure they do not happen again’. In 2011 only 7% of respondents strongly agreed
with this statement. In 2012 this doubled to 14% which is well above the national average of 11%.
We will continue our work on safety culture and will check our progress regularly by asking staff if
they feel they can ‘Stop the Line’.
C.diff reduction
We will continue to drive down hospital acquired infections including C.diff and report our rate
against other Trusts.
- 27 -
In 2012/2013 the Trust reported 13 C.diff cases against a trajectory of 7, this was a disappointment
and each case was reviewed to establish where improvements were needed. This was a significant
increase on the previous year where we reported 6. Each case was thoroughly investigated and in 3 of
the 13 cases the bacteria were linked. We therefore think that we can make a small reduction in the
number of C.diff cases through better compliance with our infection prevention and control
procedures and prudent use of antibiotics. In 2013/2014 we have an aim to reduce the number of
cases to 7 or less.
Improve the care of deteriorating patients
We aimed to provide the best care for patients by identifying rapidly if they became acutely unwell so
rapid action could be commenced. We monitored ourselves by looking at the key observations in
relation to compliance with fluid balance, observations and MEWS score. We implemented a new
observation chart and fluid balance chart that made it easier for our staff to see changes in a patient’s
condition and get help.
Over the past year we have seen an improvement in the percentage of patients with correctly
calculated MEWS scores. The graph below shows that in the last 6 months we have had 97%
compliance or above, this improvement was achieved through a huge amount of education with ward
staff led by ward mangers with the support of our specialist Outreach Team.
In 2011/2012 we collected 6 months’ worth of data and the average score for MEWS was 83.9%. In
2012/2013 the average score was 97.6% this is a 14% improvement.
- 28 -
Patient experience goals 2012/13
We aim to provide the best experience for patients, carers and families. We recognise from feedback
and complaints that we can do more to improve patient experience. We believe measurement of
patient experience is not just a case of ticking boxes and fulfilling statutory requirements. Increasingly
we want to use real-time and representative data to guide our improvement initiatives, CQC
assessments, Trust Board reports and day-to-day management.
Here is a taster of some of the things that were said about us last year.
We aimed to improve our patient experience – responsiveness to inpatient needs
Each year we participate in a National In-Patient survey, our aim is to improve our score on the
following:
patient involvement in decisions about treatment/care;
hospital staff being available to talk to about worries/concerns;
privacy when discussing condition/treatment;
being informed about side effects of medication;
being informed about who to contact if worried about condition after leaving hospital.
The table below shows our results in 2011 compared to 2012.
Question
41: Were you involved as much as you wanted
to be in discussions about your care and
treatment?
44: Did you find someone on the hospital staff
to talk to about your worries and fears?
- 29 -
2012/2013
positive
answer
percentage
52%
2011/2012
positive
answer
percentage
49%
34%
39%
Change
National
position
6%
increase
56%
13%
decrease
39%
46: Were you given enough privacy when
discussing your condition or treatment?
65: Did a member of staff tell you about
medication side effects to watch for when you
went home?
70%
68%
34%
35%
3%
increase
3%
decrease
75%
38%
70: Did hospital staff tell you who to contact if
70%
74%
5%
71%
you were worried about your condition or
decrease
treatment after you left hospital?
In two of the question areas we improved performance on last year (41 & 46) and the other 3, our
position deteriorated and we were below the national average.
In past years we have looked at the results for these 5 questions individually and thought about how
we change systems and process in relation to each one. This year we have decided to look at things
differently and are integrating the improvements into our Patient First work stream within the Top 10
Hospital project. We believe that this approach will be more successful as it will combine the aims of
the project to release time for nurses to care and give more objective measures of what we want to
improve.
Alongside the answers patients are invited to make comments where they felt the service was good
and needed improving, one patient told us:
‘Although the windows in the corridor were all being renewed, the ward windows were in a very poor
state. Old fashioned and almost impossible to open on hot days and close on cool nights!! One or two
of the older patients complained of the cold so the nurses did their best with extra blankets for them.’
We have acted on this feedback and staff comments and are currently replacing the ward windows at
the front of the hospital.
We aimed to improve the discharge information we collate
Last year we recognised that it can take a few days to get discharge information to GPs. Which can
adversely affect patients if they see their local GP and they do not have up to date information. We
wanted to drive this delay down and specifically aim for 95% of discharge summaries to be sent to
GP's within 1 working day of discharge for A&E and in-patients; and within 3 working days for out patients.
We have failed to make improvements in the timeliness of discharge summaries in the short term.
However, we have made progress with a long term sustainable solution.
At the beginning of this project the Trust was using a MS-Word based IT Tool, to enable the
completion of discharge summaries for Inpatients. A new IT tool was identified with the potential for
greater flexibility in enabling changes. The Trust conducted a pilot in August 2012 to identify any
hardware and user issues. This pilot was deemed unsuccessful for a number of reasons. The Trust
made a decision in February 2013, to purchase new software; this would enable the delivery of a high
standard discharge letter which allowed for future change. The order for the newly purchased
software was placed in March and it is anticipated to be in full use by July 2013.
- 30 -
The Trust is also aiming to introduce an electronic transmission capability for the summaries, once
the new software is in place (August 2013 latest). This should enable the immediate receipt of the
letter by primary care organisations and GP’s, once completed.
We aimed to improve our experience for service users
We have asked our patients “How likely is it that you would recommend this service to friends and
family”? By seeking feedback from every patient who uses our service we can create an organisation
with the patient at its heart. We also wanted to publish patient feedback on our website and where
patients have told us we can improve we wanted to take an action to address this need and publish it
alongside the feedback.
With patient experience firmly established as one of our top three dimensions of quality at
Hinchingbrooke, we believe that using patient experience data to drive quality and service
improvement is an essential part of service improvement across all of our services.
As a pilot site for the ‘Friends and Family Test’ Hinchingbrooke integrated it into our ’16 Point
Business plan’ this ensured our Senior Management Team were behind the initiative. We also wanted
to build a culture of transparency for all of our patient feedback, to give us the intelligence on poor
performance as well as successful performance.
We have now been collecting the ‘Friends and Family Test’ for a full year, in 2011/2012 we collected a
total of 1200 responses, for 2012/2013 we have collected a total of 5414 from in patients alone, this
is a 351% increase. The ‘Friends and Family Test’ provides richer data which we can use to measure
patient experience and narrative statements give real time knowledge. (Please see results below).
Hinchingbrooke NET promoter scores for year 2012/2013 with trend line at 75)
The graph above shows that we went into the new financial year with a score of 93, although this set
a bar for other Trusts to achieve, it was clear that this result would be difficult to maintain. Therefore
- 31 -
we set an objective to maintain a ‘top ten position’. Our success for the year was to remain in the top
quartile of 46 Trusts for the year. We dipped in August, we think this may have been a result of
changes to our wards and we opened a Short Stay Unit for our patients. We believe that any large
change in wards will affect NET promoter scores and we need to support staff to provide a seamless
service.
This shows the breakdown of Promoters who are extremely likely to recommend Hinchingbrooke, Passives who are likely to recommend,
and Detractors who would not recommend.
In the yearly picture above we had 2% of patients that would not recommend us (detractors); the
responses ranged from food not warm enough to improvements in the discharge process.
Break down of improvements from all responses
We are conscious of the need to balance individual patient’s expectations of improvement against
the need to make positive changes for the majority of patients. To do this we monitor the top ten
improvements required Trust wide. We discuss these needs at our Governance Board monthly.
Locally in each of the divisions we hold Clinical Unit Governance meetings and we break down the
feedback data into each of the Clinical Units to identify local actions and improvement.
- 32 -
What we could improve
What Hinchingbrooke did
Shows some of the changes we have made as a result of patient feedback
Next Steps for patient feedback
To continue ‘Board to Ward’ information access ensuring that real time patient feedback is at the
route of all discussion.
We want to build a better culture in which patients feel better informed to make their own decisions
about their care.
To continue to track trends and target improvements, which are sustainable and measurable.
We aimed to Make Every Contact Count (MECC)
We wanted to make sure every time our patients were seen by one of our healthcare professionals
that they were given appropriate information about a healthy lifestyle concentrating on alcohol and
smoking cessation. We wanted to train our staff so they were competent to deliver this information
in a way that suited our patients.
The Trust has a role in promoting healthy lifestyles, and the prevention of poor health. The Trust
employs staff who can provide brief opportunistic advice on smoking cessation, as this can be
successful and 1 in 20 of those receiving the advice will quit smoking.
The Trust is prepared for this as it has a culture that empowers and supports continuous health
improvements through the contacts it has with individuals.
The benefits of MECC include:
•
•
•
Better health for patients and staff
Reduction of long-term expenditure on preventable ill health
Reduced admissions, readmissions and bed-days
- 33 -
We identified a making every contact count co-ordinator to achieve this goal by ensuring that a
robust system to record training delivery is in place.
Alcohol - FAST Alcohol screening is embedded into staff induction for the specified areas. The Trust
has successfully attained a 90.7% rate identifying appropriate staff to deliver brief advice to patients.
Smoking - A flexible training system has been developed in conjunction with ward managers to
accommodate nursing staff undertaking smoking brief advice training. The Trust has successfully
attained a 92.9% rate identifying appropriate staff to deliver brief advice to patients.
Moving forward, the Trust aims to have this training embedded into the mandatory induction thereby
capturing all new members of staff without the need to withdraw nurses from ward areas to achieve
future targets.
Clinical effectiveness goals 2012/2013
In our hospital we aim to provide high quality health care services using best available evidence to
give the local health care community value for money. Our consultants and teams receive yearly
appraisals to ensure they have updated their skills and practice. Through analysis of complaints,
incidents, claims, audit results and inquests we chose the following areas to improve clinical
effectiveness:
We aimed to improve the care pathway of patients with dementia
Dementia is a significant challenge for the NHS - 25% of beds are occupied by people with dementia,
people with dementia have an increased length of stay and there is often a sense they are ‘in the
wrong place’. We aimed to improve awareness and diagnosis of dementia, using risk assessment.
Specifically we wanted to implement a dementia screening tool, dementia risk assessment and
referral for specialist diagnosis.
The project to improve the care of dementia patients has been difficult, as a small hospital we did not
have staff who were employed solely to provide a dementia service. We did not fully implement the
dementia screening tool in the year and failed to achieve referral.
We looked again at the needs of our community and the patients who come into hospital and
recognised that we needed a specialist team to take this vital work forwards. In February 2013 we
employed a new Consultant Psychiatrist Dr Pieters, a doctor and also a specialist nurse to support
her, Dr Bashford is our Clinical Director and is leading the work on dementia. In May 2013 a new and
improved dementia screening tool will be implemented ensuring patients and carers can access
medical support.
Implement the Enhanced Recovery Programme
In our gynaecology service we wanted to implement the most evidence based care that gave our
patients the best possible journey through surgery with excellent recovery times. To achieve this we
planned to implement the DOH’s guidance on Enhanced Recovery post elective surgery. By the end of
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2012/2013 this programme was offered to all eligible patients undergoing major gynaecological
laparoscopic and urogynaecological procedures. This was a multidisciplinary collaboration involving
gynae surgeons, anaesthetists, pre op and ward nurses, pain team, pharmacy and data co-ordinators.
The programme was successfully implemented and data was collected prospectively on the DOH
Enhanced Recovery Program database. The program successfully reduced average length of stay for
patients undergoing major gynaecological surgery by 25% (1.71 to 1.28 days) and patient experience
was maintained.
We aimed to improve end of life care
Last year we wanted to work with the local health economy to improve the care of palliative patients.
To do this we planned to continue the development of palliative care training, education and
awareness that included;
identification of patients approaching the end of their lives, holding conversations with
patients entering the palliative phase of illness, concerning their future care needs, and the
communication skills needed for these conversations
use of the End of Life Care tools such as the ‘Preferred Priorities for Care document’ and
understand the information needs of GPs and community services on discharge
we aimed to train 50% of identified staff by the end of 2012/2013.
Dr Mathews our lead consultant for palliative care approached this by providing education for staff
members who regularly come into contact with patients at the end of their lives.
In 2012/2013 she personally trained over 150 eligible staff in total, just over 50% of the target group.
The training covered communication, care needs and use of end of life care tools.
We also identified patients who were thought to be in their last year of life and through discharge
letters we asked GPs to add these patients to the gold standard care register. This also included
documenting details of any conversation that had been held with the patients about diagnosis
prognosis and changes to the care plan. We referred over 50% of relevant patients which was the aim
we had been set with the PCT.
Dr Mathews will be progressing the quality improvements for end of life care in the forthcoming year.
The team will implement the ‘Amber Care Bundle’ on 2 wards, the bundle is a tool to identify patients
who are at risk of passing away during their hospital admission and ensures they have prompt senior
assessment and on-going quality communication daily with patients and relatives during the
admission.
We aimed to improve sharing of information
The summary care record is a patient record that can be viewed with patient’s permission by
healthcare organisations in different locations. This type of record has been proven to improve the
patient experience and outcomes as vital information on a patient’s condition can be available when
they present at different organisations. Last year we committed to work with other healthcare
providers to ensure we put in place a process to seek patient consent in accessing and using this type
- 35 -
of record. We aimed to have identified the staff that needed to access records and put in place
systems to enable the records to be viewed and used by April 2013.
We worked with our commissioning colleagues to devise a safe system to access patient’s records.
We chose nine GP surgeries; we looked at the number of patients they had who were classified as
over 75 likely to be admitted to hospital and vulnerable. This sample was extremely small and meant
that we did not have enough patients to pilot a wide scale project that would engage enough staff to
put in place a new process. We are hopeful that the healthcare community will continue to utilise
summary care records. We believe that our work to introduce IT systems that can communicate and
be accessed by local communities will benefit patients in a similar way.
- 36 -
Part 3
3.1
Work to support quality in our hospital
Research
Research helps the NHS to improve the quality of care and the future health of the population. Health
care research in the UK is classed as research that has been agreed by the National Research Ethics
Service (NRES). The Department of Health has mandated that we include the following statement on
research;
The number of patients receiving NHS services provided by Hinchingbrooke Health care NHS Trust
in 2012/2013 that were recruited during that period to participate in clinical research approved by
an ethics committee was 306.
In 2012/2013 we participated in 115 studies (49% increase from last year), of which 86 were portfolio
(65% increase from last year), spread across 14 medical specialties (17% increase from last year). We
have an even balance of interventional and observational studies, of which 13% were commercially
sponsored. We were actively recruiting into 36 studies (reduction of 18% from last year), and setting
up a further 11 (reduction of 9% from last year).
By participating in high quality clinical trials, we are able to provide additional tests to monitor
response to treatment, and follow-up patients for longer than would often occur during routine
clinical care. Our Oncology Department has continued to increase their research activity by 20% from
last year and are running 30 studies in 2012/2013. Patients benefit from participating in these trials as
they receive regular/close monitoring in terms of extra CT scans, for example, (which they would not
normally get with standard treatment) and follow-ups for sometimes 7-10 years depending on the
study. Interestingly, for every one of our new participants this year, there are 2-3 participants in
follow-up, a large proportion of which are in follow-up for ten years or more. The high level of
retention of participants is a testament to the quality of care our staff are providing.
Our clinical staff stay up to date with the latest treatment possibilities and active participation in
research ideas leads to successful patient outcomes. Approximately 50 members of our staff coordinated and ran research approved by a research ethics committee during 2012/2013. There has
been a gradual increase in new clinical trials with Hinchingbrooke as the lead site and our consultants
as lead investigators. An influx of newly appointed consultants with a research background has led to
an increase in the number of clinical specialties within the Trust that have started or are planning new
NHS research trials.
Participation in clinical research demonstrates our commitment to improving the quality of care we
offer and to making our contribution to wider health improvement. The Huntingdon Glaucoma
Diagnostic & Research Centre is the most active in NHS ophthalmology research, bringing the benefits
of research to a large number of patients in the region. We are currently involved in 10 studies, with
various studies in set-up, and are also engaging in Hinchingbrooke-led research. Research conducted
at Hinchingbrooke has provided newly-referred patients with access to the most modern imaging
technology available for diagnosis of glaucoma. In addition, research into new treatment pathways
for glaucoma care has allowed our researchers to publish quality outcomes for patients in shared
care, one of the very few centres to do this in the UK.
- 37 -
For 2013/2014 we will be aiming to increase the number of departments and staff engaged in
research. We are expecting further developments in Emergency Medicine and Obstetrics and
Gynaecology amongst other specialties.
An exciting development in 2013 was the new East Midlands Health Innovation & Education Cluster
(HEIC) clinical academic careers programme, our orthoptist Marina Parker, and midwife Charlotte
Clayton are both part of this program.
The project aims to develop allied health professionals for a clinical academic career, giving them
experience of research without removing them entirely from their clinical day jobs. This means that
interns like Marina and Charlotte will be able to deliver the findings of their research directly to
patients and therefore improve patient care.
The internship lasts for 4 months and the Trust receives funding to cover backfill and expenses whilst
Marina and Charlotte are working on the project. Interns get to spend 3 days a week working on a
project of their choice and are allocated a mentor to help them through the process. Some of the
areas covered on the programme include data analysis
and statistics, report writing, and presentation skills.
Charlotte Clayton, has been a midwife at
Hinchingbrooke since 2009 has chosen September
2012 NICE standards for antenatal care as her project.
Charlotte chose this course as she had a strong desire
to one day go into a research career within midwifery
since being at university, but wanted to consolidate
her practice. She is sometimes frustrated by areas
within clinical practice that lack evidence base.
Marina Parker an orthoptist at Hinchingbrooke
believes it is an excellent opportunity for any health
professional with an interest in research.
Charlotte Clayton and Marina Parker at
work in the library
3.2
Audit
National projects (not all of which are clinical audits) can provide indications of services where quality
improvement is needed on a national scale. They also tell us where our services stand compared to
others and, therefore, how much improvement is needed. They may draw attention to areas where
care provides a particular challenge such as dementia care in acute hospitals where staff may have
limited training in mental health treatment. Participation is strongly encouraged and prioritised.
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During 2012/2013, 33 national clinical audits and 6 national confidential enquiries covered NHS
services that Hinchingbrooke Health Care NHS Trust provides.
During that period Hinchingbrooke Health Care NHS Trust participated in 76% of national clinical
audits and 100% of national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Hinchingbrooke Health Care
NHS Trust was eligible to participate in during 2012/2013 can be found in the table below.
It should be noted that there may not always be cases appropriate for submission to each project.
The national clinical audits and national confidential enquiries that Hinchingbrooke Health Care
NHS participated in, and for which data collection was completed during 2012/2013, are listed in
the table below alongside the number of cases submitted to each audit or enquiry, where possible,
as a percentage of the number of registered cases required by the terms of that audit or enquiry.
The reports of 22* national clinical audits were reviewed by the provider in 2012/2013 and
Hinchingbrooke Health Care NHS Trust intends to take actions to improve the quality of health
care provided, a description of actions from some of the national audits is in our audit
improvement section.
The reports of 111 local clinical audits were reviewed by the provider in 2012/2013 and
Hinchingbrooke Health Care NHS Trust intends to take the actions to improve the quality of health
care provided a description of actions can be found in our audit improvement section.
* not all projects have been completed or the report received for review
The table below shows the national clinical audits and national confidential enquiries that we
participated in during 2012/2013 and we have included the number of cases where the information is
known and where there is an established number of cases requested. Some of the projects request
all of the relevant cases over the period.
- 39 -
3.2.1 Audit Improvement
Took part
Did not
take part
Name of audit or confidential enquiry
Further details of project
Not
applicable
Acute
Adult community acquired pneumonia (British
Thoracic Society)
The British Thoracic Society (BTS) has an
extensive audit programme. For small hospitals
this becomes excessive and selection of audits
most helpful to the greatest improvements at the
Trust must be made.
Adult critical care (Case Mix Programme – ICNARC
CMP)
On-going (as cases arise)
Emergency Laparotomy
Registered to participate 2013/14
Emergency use of oxygen (British Thoracic Society)
Please see comment on BTS audits above
National Joint Registry (NJR)
Done by individual surgeons
Non-invasive ventilation - adults (British Thoracic
Society)
Please see comment on BTS audits above.
Patient Outcome and Death (NCEPOD)
On-going (as cases arise). Please also see further
table below.
Renal colic (College of Emergency Medicine)
All patients over the age of 18 and who are in
moderate or severe pain
Severe sepsis & septic
Emergency Medicine)
shock
(College of
Severe trauma
Network)
Audit
&
(Trauma
Research
As requested
Have participated in the past and found few cases
that apply.
Blood and Transplant
Intra-thoracic
transplantation
Transplant Registry)
(NHSBT
UK
Transplant surgery not performed
National Comparative Audit of Blood Transfusion
Results not yet available
Potential donor audit (NHS Blood & Transplant)
As availability occurs and agreement provided
- 40 -
Cancer
Bowel cancer (NBOCAP)
115 cases submitted (114 cases expected).
Head and neck oncology (DAHNO)
Not enough cases to be valuable.
Lung cancer (NLCA)
68 cases submitted (35 cases expected)
Oesophago-gastric cancer (NAOGC)
22 cases submitted
expected)
(less than 100 cases
Heart
Acute coronary syndrome or Acute myocardial
infarction (MINAP)
Cases in intensive care only
Adult cardiac surgery audit (ACS)
Not applicable
Cardiac arrhythmia (HRM)
Not applicable
Congenital heart disease (Paediatric cardiac
surgery) (CHD)
Not applicable
Coronary angioplasty
Not applicable
Heart failure (HF)
Trust has below the requested number of cases
National Cardiac Arrest Audit (NCAA)
As they occur. It is believed that the appropriate
cases were submitted.
Peripheral vascular surgery
Surgery Database, NVD)
Not applicable
(VSGBI Vascular
Pulmonary hypertension (Pulmonary Hypertension
Audit)
Not a designated centre
Long term conditions
Adult asthma (British Thoracic Society)
The Trust did not participate in the national
project but did collect the local data at a later
date and reviewed it against the national
observations.
Asthma Deaths (NRAD)
Results not yet available
Bronchiectasis (British Thoracic Society)
Please see comment on BTS audits above.
COPD (NOT the COPD audit run by the British
Thoracic Society)
Please see comment on BTS audits above.
National Diabetes Inpatient Audit (NADIA)
100% of patients who agreed
Diabetes (Paediatric) (NPDA)
Cambridgeshire Community Services provides
paediatric care on-site
- 41 -
Inflammatory bowel disease (IBD) Includes:
Paediatric Inflammatory Bowel Disease Services
(previously listed separately on 2010/11 QA list)
Results not yet available
Pain database
No pain clinic
Renal replacement therapy (Renal Registry)
Transplant surgery not performed
Renal transplantation (NHSBT UK Transplant
Registry)
Not applicable
Mental Health
National audit of psychological therapies (NAPT)
Mental Health services are provided by the
Mental Health Trust and not Hinchingbrooke
Health Care NHS Trust
Prescribing in mental health services (POMH)
Suicide and homicide in mental health (NCISH)
Older People
Carotid interventions audit (CIA)
Service not provided
Fractured neck of femur
100% of reported cases were subject to a root
cause analysis and reported to commissioners for
audit and trending
Hip fracture database (NHFD)
On-going
National dementia audit (NAD)
100% of requested cases submitted
Parkinson's disease (National Parkinson's Audit)
100% of cases submitted
Sentinel
Organisational
Stroke
(SSNAP)
–
Treatment
Please see below. Outline of organisation – no
patient cases required.
No longer full service stroke unit.
Other
PROMs - National Patient Reported Outcome
Measurement Programme for Elective Surgery:
Hip replacement
Knee replacement
Varicose Veins
Groin Hernia
Please see section 2 For further information
(counted as 4 audits in percentage calculations)
Risk factors (National Health Promotion in
Hospitals Audit)
No lead identified
Women’s & Children’s Health
Maternal infant and perinatal (MBRRACE-UK)*
- 42 -
Cases occurring
Previously listed as Perinatal Mortality
Child Health (CHR-UK)
Inpatient Paediatric Services are provided by
Cambridgeshire Community Services and not
Hinchingbrooke Health Care NHS Trust
Epilepsy 12 audit (Childhood Epilepsy)
Neonatal intensive and special care (NNAP)
Paediatric asthma (British Thoracic Society)
Paediatric fever (College of Emergency Medicine)
Children presenting included
Paediatric intensive care (PICANet)
Inpatient Paediatric Services are provided by
Cambridgeshire Community Services and not
Hinchingbrooke Health Care NHS Trust
Paediatric pneumonia (British Thoracic Society)
Hospitals were eligible to enter data into 4 NCEPOD studies. Hinchingbrooke’s participation was:
Name of other confidential enquiry
Further details of project
Subarachnoid Haemorrhage( still open)
To date, 1 case excluded
Alcohol Related Liver Disease
3 cases included with 3 clinical questionnaires
returned and 2 case notes returned.
Organisational questionnaire returned.
Bariatric Surgery
No cases
Cardiac Arrest Procedures
1 case included with 1 prospective form and
case notes returned.
Organisational questionnaire returned.
The Trust also participates in other projects with national information coverage such as KC65 for
colposcopy services.
The National Cardiac Arrest Audit shows that Hinchingbrooke’s survival rates have risen steadily over
the years we have participated and continue to be above the national average. Monitoring and
follow-up carry on.
The results of the second cycle of the National Audit of Dementia showed that the majority of metrics
have significantly improved since the first cycle and compare favourably to the national norms. A
very comprehensive and effective action plan, drawn up by a senior nurse following the first cycle, (in
addition to increased staff awareness and effort) is credited with leading to the improvements. A
new action plan based on the latest audit outcomes has been drafted and distributed for discussion
and amendments.
- 43 -
This is in addition to local initiatives to make the primary ward more ‘patient friendly’ for people with
this diagnosis (e.g. the use of red items where they have been shown to assist.)
During the previous year, a regional decision was taken to change stroke care provision to a ‘hub and
spoke’ model in Cambridgeshire. It was determined that the larger hospitals, who were thought to be
able to provide the required continuous cover for thrombolysis, would provide the acute care and
Hinchingbrooke would repatriate stroke patients for rehabilitation care (where necessary) following
the acute phase.
The stroke service provides monthly monitoring metrics to regional commissioning and network
groups on the aspects of the services provided.
We also take part in national audits of various Royal Colleges. For example, College of Emergency
Medicine projects, such as Feverish Children, are undertaken. On occasion, we assist other Trusts
with their national audits. In the case of the Ambulance Service national audit of outcome of
Myocardial Infarction patients, we provide the requested outcomes about patients brought to
Hinchingbrooke by the East of England Ambulance Trust.
Examples of regional projects we participated in to help our local healthcare economy are:
Improving Safe and Accurate Transfer of Medicines-related Written Discharge Summary
Information (East & South East England Specialist Pharmacy Services, East of England,
London, South Central & South East Coast) measuring pharmacy contributions to all take
home drugs over a 2 day period;
Compliance with NICE Clinical Guideline 83: ‘Rehabilitation after critical illness, Norfolk,
Suffolk and Cambridgeshire Critical Care Network’;
Multicentre Acute Pancreatitis Audit - a trainee-led multicentre audit on the management of
acute pancreatitis to identify variations of practice against the national standards
recommended by the UK Working Party on Acute Pancreatitis;
Privacy and Dignity for patients over 65 years of age, Cambridgeshire Local Involvement
Network.
Local audit projects help us to review areas where our internal risk assessments have indicated that
we might need particular attention and, as they are able to collect and specify data on the potential
causes (which the national audits cannot sensibly provide), they are more useful in delivering locally
required remedies with a much quicker time to implementation of remedial action than national
projects (which may require further exploration into the local causes of the outcomes). We are
committed, therefore, to balance our audit/quality reviews between local, regional and national
projects.
- 44 -
In addition, local projects provide the opportunity to teach auditing skills which nationally designed
and reported projects do not. It is believed that this is a responsibility of every Trust in order to
improve the quality, reliability and usefulness of audit and other quality projects. At the present
time, these skills are not covered in national medical training. We involve staff in carrying out the
whole process, with suitable support, to provide the best system for learning.
Some of the local projects undertaken include:
Best practice for a patient with a fractured neck of their femur (hip fracture) is to get patients to
surgery within 36 hours of arrival; we reviewed our performance.
The first review of this surgery in March to August 2010 showed that 54% of the cases were within
this time. Actions put in place to improve this performance were: writing a procedure for the
emergency team that was in effect by February 2012; holding a Trauma meeting with 2 consultants
and a trauma nurse present Monday to Friday and setting priorities for these cases with the
emergency team.
By the third review in 2012, 79% of cases met the target.
Prior to 2004, it was nationally accepted that all drugs which a patient brought into hospital should be
sent to the pharmacy and destroyed. To reduce wastage, ward based pharmacy teams and a
patient’s own drug scheme were introduced where patients brought their own drugs into hospital
and those that were suitable were used during the patients’ stay in hospital and returned to the
patient at discharge.
Four reviews of the scheme have taken place with the value of the drugs returned at £3,168 in the
first review and £8,354 in the fourth review. Of these, the reusable drugs were £1,273 at first and
£8,074 in the last review. In the last measurement, 97% of the drugs were reused which was 25%
higher than the first review and a saving that can now provide other services to patients.
Based on National Chemotherapy Advisory Group information, patients presenting with Neutropenic
Sepsis should receive antibiotics within 1 hour. In January to December 2010, 20% of patients had
received antibiotics in 1 hour. A system, called a Patient Group Directive, was developed to empower
those nurses trained in its use to give IV antibiotics where patients were suspected of having a
diagnosis of Neutropenic Sepsis ahead of the patient being seen by medical staff.
In July 2011 to March 2012, whether these patients were admitted to any of three areas, the average
was 58% success in getting antibiotics to the patient within the hour. 25% of the patients did not
have the time recorded and were deemed not to have received the antibiotics on time, however,
proper recording of the time administered might have shown that the success rate was higher.
- 45 -
The Performance Framework for nursing is used in all ward areas and returns are submitted
quarterly, which includes such reviews as:
Essence of Care benchmarks relating to Privacy and Dignity;
Communication;
Record keeping;
Self-care;
Saving Lives;
Hand wash audits.
Surveys are also used to improve the quality of our service. In addition to the nationally required
survey about patient views on whether hospital services can be recommended administered locally
and the national in-patient survey, it is also useful to seek further more specific information about
services from the patients/carers we serve.
The Trust also participated in the Imaging and Radiotherapy Access Surveys, undertaken on behalf of
the Department of Health. “If the surveys demonstrate a willingness by patients to contemplate the
use of imaging and radiotherapy services outside normal hospital hours, and a change of policy is
undertaken, this may contribute to the reduction of waiting times for imaging investigations and for
radiotherapy treatment. This in turn will reduce concern”. The information about the views of the
patients has not been returned yet. Locally, a survey to all users in the Trust was delivered via the email system to assess the services from the staff view to provide a full review.
The Trust has an Occupational Health Service that provides support and services to the hospital as
well as other public and private organisations. Those attending were given a questionnaire to
determine if those being seen understood the role of the service, if their questions were answered in
an understandable manner, if they were listened to, if it was clear what would happen next, if the
report that they planned to send to the manager/HR professional was discussed with the patient. On
the scoring system, 92.95% of the clients were satisfied but clearer directions will be sent to assist
those attending the department to find it.
Documentation complexity is a problem in the NHS and relates directly to the safety and experience
of the patient. During the year an integrated project using both an audit and a staff survey was used
to assist in providing documentation that could be used with relative ease, did not duplicate, could
provide convenient access without compromising confidentiality, etc. The follow-up cycle showed
that non-sequential notes were reduced from 12% to 0%, blank documents had reduced by half, and
duplication had fallen from 56% to 0%. Rather than begin separated into medical, nursing, care plan,
etc. areas, the new system shows that the majority of information is filed in the integrated notes.
This saved time for staff, as well as making the patient safer.
- 46 -
3.3
Data quality
Data quality can affect patient safety, at our Trust we believe quality data recording is essential in
caring for patients safely and effectively. Data is recorded in a number of ways but primarily in
medical records and electronic patient records. We believe that by ensuring data is accurate and
recorded in line with best practice standards we can positively affect patient outcomes.
The information in patient’s medical records about their diagnosis and treatment is used by us to
record the volume of work we have undertaken. This information helps us to decide if we are
providing our local health population with value for money.
The Department of Health recognises the importance of data quality and has asked for the statement
below to be completed. From this table you can see that the high percentage of patients with their
NHS number recorded shows we have a reliable process for recording information.
Hinchingbrooke Health Care NHS Trust will be taking the following actions to improve data quality:
Data quality groups meet across the Trust to monitor compliance rates with key data fields, where
they identify an issue the clinical area are tasked with finding a solution. These groups also act to
provide staff with guidance and education.
Hinchingbrooke Health Care NHS Trust submitted records during 2012/2013 to the Secondary
Uses Service for inclusion in the Hospital Episode Statistics which are included in the latest
published data. The percentage of records in the published data which included the patient’s valid
NHS number was:
99.8% for admitted patient care;
99.8% for outpatient care; and
99.6% for accident and emergency care.
Which included the patient’s valid General Medical Practice Code was:
99.8% for admitted patient care;
99.9% for outpatient care; and
99.8% for accident and emergency care.
Hinchingbrooke Health Care NHS Trust was subject to the Payment by Results clinical coding audit
during 2012/2013 by the Audit Commission. The error rates are reported in the latest published
audit for that period for diagnoses and treatment coding (clinical coding) and were:
Primary diagnosis incorrect coding 5.0%
Secondary diagnosis incorrect coding 9.38%
Primary procedures incorrect coding 15.68%
Secondary procedures incorrect coding 6.88%
- 47 -
The recommendations from the clinical coding audit were to:
1. Improve the identification and coding of co-morbidities and secondary codes and remind
coders that they should only code co-morbidities that have been recorded in the spell being
coded.
2. Address the specific issues noted in the audit including:
improving the extraction of information for coding;
reminding the coders to index to the furthest level of specificity;
reinforcing national standards for sequencing and coding; and
ensuring coders only code symptoms where a diagnosis is not made.
3. Put a process in place to ensure that the Trust receives and updates coders on all coding
clinics in a timely manner.
3.4
Information Governance
We take our responsibility for information security seriously, as a result we have made information
governance training mandatory for all our staff. This helps to ensure patients feel that their personal
information is treated in line with the law and good practice.
NHS Trusts must participate in a national assessment of information governance compliance called
the Information Governance Toolkit. The Department of Health have requested the statement below
to indicate our compliance.
Hinchingbrooke Health Care NHS Trusts Information Toolkit Assessment Report score for
2012/2013 was 77% and rated as a pass (Green).
Hinchingbrooke Health Care NHS Trust continually reviews its Information Governance Framework.
This is to ensure that all personal and medical information held are managed, handled, used and
disclosed in accordance with the law and best practice. In addition to the mandated information
governance training and the information asset management framework, data quality and clinical
records management has been an area of focus and as a result improvement has been made across
the Trust.
The Trust is currently developing an Information Governance Improvement plan to improve scores for
this year from level 2 to level 3
3.5
Our improvement goals for 2013/2014
We have decided to focus our local improvement goals on 4 discrete areas, namely, Best Patient
Experience, Best Clinical Outcomes, Most Engaged Staff and Best Value. The 3 quality improvement
areas of safety experience and effectiveness fit into these four areas of focus. We selected the 4
areas of focus in consultation with our staff and they form part of our business plan to be a Top 10
District General Hospital. Our overriding motto is “Making Healthcare Better”. Within these 4 areas of
- 48 -
focus we plan to further improve the elderly care pathway by working across the health community
to encourage a ‘seamless care’ transition from acute care to community care whilst at the same time
reducing avoidable delays in discharges to a safe environment.
We have developed a newly refurbished Education and Training Centre in 2013 and this will be
utilised in 2013/2014 to build on the strengths identified in a very positive review of Junior Doctor
education and training by Dr Mark Lillicrap of the East of England Deanery.
We will also increase public scrutiny by the use of volunteers in service redesign and delivery, just as
we did in the review and introduction of our Community Transition Unit in late 2012 and early 2013.
Next year we will also aim to improve our quality outcomes for the national mandated areas of:
Mortality;
PROMS;
28 day readmissions;
Improving responsiveness to personal needs;
Staff who would recommend our care to friends and family;
VTE risk assessment rates;
Reducing C.diff;
Reducing serious incidents.
*This list may be subject to change and expansion nationally.
Patient Safety
We want to improve our safety culture by increasing the feedback we give to staff after they
report an incident. We want to create an environment where staff feel able to speak up for
patient safety safe in the knowledge that they will be listened to and action taken. We will
measure our success using a safety culture survey and incident report feedback rates.
Patient Experience
We want to give patients the best experience by enabling our nurses to spend as much time as
possible with their patients. We will overhaul process so that patient contact time is increased
to two thirds of nursing time.
We will measure the amount of time nurses spend with their patients
Patients will be the centre of our hospital, we will continue to ask each patient three simple
questions; what did we do well? What could we have done better? Would you recommend
Hinchingbrooke to a family member or friend? We want to get it right for our patients and will
strive to be a Top 10 hospital for patients willing to recommend us.
We will measure and publish the percentage of patients who would recommend us.
- 49 -
Clinical Outcomes
We will improve the outcomes for patients by reducing length of stay for patients through
implementing the best evidence based practice and pathways in practice. We will redesign our
medical care pathways supported by the best diagnostics, treatment and everyday care. This will
enable our patients to return to the community quickly with the best experience and outcomes.
We will measure our success through the average length of stay data over the last 12 months.
We will provide updates on our progress through the Top 10 Safest Hospital Report that the public
can view in our Trust Board papers.
- 50 -
Summary and feedback
This report has been designed with involvement from staff, patients and local partnership groups. If
you would like to provide feedback on the content of this report and suggest improvements for
future Quality Accounts please e-mail lisa.deacon@nhs.net or write to Lisa Deacon, Head of Risk,
Hinchingbrooke Hospital, Huntingdon, PE29 6NT.
Glossary of terms
Catheter Associated Urinary
Tract Infection (CAUTI):
CCC:
Commissioners:
Central Line Infection (CLI):
CQC:
CQUINs:
DTC:
Fall:
GTT
Hypothermic:
HSMR:
LMWH:
MEWS:
Morbidity:
Mortality:
Outreach
Palliative Care
All patients with a positive blood culture will be monitored for CAUTI.
A catheter associated urinary tract infection will be defined as any
patient, where an indwelling catheter is in situ or has been removed
within 3 days, and where the patient has more than one of the Health
Protection Agency symptoms together with a positive urine culture.
Critical Care Centre is where high dependency patients are nursed
and patients are often ventilated.
The NHS Bodies that buy services from Hinchingbrooke for the local
population.
An infection that originated in a line used to support a patient with
medication/fluid/monitoring in critical care.
Care Quality Commission, the independent regulator for Health Care.
Commissioning for Quality and Innovation is an incentive scheme to
encourage providers (hospitals) with incentive payments to develop
new or improved ways of working to assure patient safety.
Drugs and Therapeutics Committee, this committee overseas
medication management at our Trust.
Falls are defined as “inadvertently coming to rest on the ground or
other lower level with or without loss of consciousness or injury” we
exclude faints and seizures (Davison & Marrinan, 2007).
Global Trigger Tool is an audit of patients who have been admitted to
the hospital; it assesses standards of care.
Our body’s normal temperature is 36.5 degrees if it falls significantly
below this after an operation it can hinder recovery. We measure
adults who have had surgery requiring general anaesthetic.
Hospitalised Standardised Mortality Rate, this is a ratio of a patient’s
risk of dying using 80% of the most common procedures.
Low molecular weight Heparin is a drug used to reduce the
stickiness/clotting of blood.
The Modified Early Warning Score is a ‘Track and Trigger’ tool
designed to identify the adult deteriorating patient.
A medical word used for illness or disease.
A medical word for death.
Is a specialist team of skilled staff who can be called to review
patients to prevent deterioration.
This is when we care for a patient who has life threatening illness
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Glossary of terms
Pressure Ulcer:
Quality:
Quality Account:
RAG
RCA
SI
SSI
TVN
VTE
VAP
Waterlow
WHO Checklist
through the identification and relief of symptoms.
Pressure ulcers occur to the skin when underlying tissue becomes
damaged. The degree of damage is given a grade from 1 to 4:
Grade 1 – the top layer of the skin turns red and can become
hard, hot and swollen;
Grade 2 – the top layer of skin is damaged and can blister or look
grazed;
Grade 3 – the top and middle layers of the skin are damaged;
Grade 4 – extensive skin and tissue damage which can extend
down to the bone. (Scottish adapted European Pressure Ulcer
Advisory Panel, 2009).
Healthcare is defined as ‘safe has the right outcomes, including
clinical outcomes (for example, do people get the right treatment and
are they well cared for?); is a good experience for the people who use
it, their careers and their families; helps to prevent illness, and
promotes healthy, independent living; is available to those who need
it when they need it; and provides good value for money’ (Care
Quality Commission, 2009).
An annual look back on a Trust’s results for quality and plans for the
forthcoming year.
A way of measuring performance (Red, Amber, Green).
Root cause analysis is a method used to investigate patient harm
events.
Serious Incidents are incidents which cause severe harm to patients
and require RCA investigation and actions to ensure lessons are learnt
and events do not re-occur. These incidents are reported to and
monitored by the Trust’s Commissioners.
Surgical Site Infection.
Tissue Viability Nurse – a nurse who has expertise in pressure ulcer
prevention.
Venous Thrombus Embolism is a life threatening event where blood
clots can form in the body’s circulation and travel to the lungs making
breathing difficult. All patients admitted to the hospital and with
lower limb casts should be assessed for the risks of blood clots and
treatment started if appropriate.
Ventilator Acquired Pneumonia, this is a chest infection that can
occur after a patient is mechanically ventilated.
This is a risk scoring tool used by nurses to identify the risk a patient
has of developing pressure ulcers or skin break down.
The World Health Organisation safer surgery checklist to be used by
surgical teams before, during and after an operation.
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Appendix 1 Electronic Links
Business plan 2012/2013
2012 2013
hinchingbrooke 16 point plan.pdf
Business plan 2013/2014
Hinchingbrooke 16
point plan.pdf
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Appendix 2 – Changes made to the Final Quality Account after Receipt of these
statements from Overview and Scrutiny, CCG and Health Watch.
Section Heading
What others say about us
Change
We have added in direct quote from Health
Watch.
We have explained the terms DANI.
We have added our performance data for
emergency readmissions to hospital within 28
days of discharge.
We have added our performance data for rate of
c.difficile per 100,000 bed days.
We have amended the percentage change as this
previously inaccurate.
We have added more details entitled Audit
Improvement.
We have amended the percentage illustrated as
this previously inaccurate.
We have added more contextual narrative to this
section to make it more clear.
Care Quality Commission
Proms
Rate of C.difficile
Patient Experience Goals 2012/2013
Audit Improvement
Date Quality
Our Improvement Goals 2013/2014
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Appendix 3 Limited assurance report External Audit.
INDEPENDENT AUDITOR’S LIMITED ASSURANCE REPORT TO THE DIRECTORS OF HINCHINGBROOKE
HEALTH CARE NHS TRUST ON THE ANNUAL QUALITY ACCOUNT
We are required by the Audit Commission to perform an independent assurance engagement in
respect of Hinchingbrooke Health Care NHS Trust’s Quality Account for the year ended 31 March
2013 (“the Quality Account”) and certain performance indicators contained therein as part of our
work under section 5(1)(e) of the Audit Commission Act 1998 (“the Act”). NHS trusts are required by
section 8 of the Health Act 2009 to publish a quality account which must include prescribed
information set out in The National Health Service (Quality Account) Regulations 2010, the National
Health Service (Quality Account) Amendment Regulations 2011 and the National Health Service
(Quality Account) Amendment Regulations 2012 (“the Regulations”).
Scope and subject matter
The indicators for the year ended 31 March 2013 subject to limited assurance consist of the
following indicators:
Percentage of patient safety incidents that resulted in severe harm or death; and
Rate of clostridium difficile infections per 100,000 bed days.
We refer to these two indicators collectively as “the indicators”.
Respective responsibilities of Directors and auditor
The Directors are required under the Health Act 2009 to prepare a Quality Account for each financial
year. The Department of Health has issued guidance on the form and content of annual Quality
Accounts (which incorporates the legal requirements in the Health Act 2009 and the Regulations).
In preparing the Quality Account, the Directors are required to take steps to satisfy themselves that:
the Quality Account presents a balanced picture of the trust’s performance over the period
covered;
the performance information reported in the Quality Account is reliable and accurate;
there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to review to
confirm that they are working effectively in practice;
the data underpinning the measures of performance reported in the Quality Account is
robust and reliable, conforms to specified data quality standards and prescribed definitions,
and is subject to appropriate scrutiny and review; and
the Quality Account has been prepared in accordance with Department of Health guidance.
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The Directors are required to confirm compliance with these requirements in a statement of
directors’ responsibilities within the Quality Account.
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether
anything has come to our attention that causes us to believe that:
the Quality Account is not prepared in all material respects in line with the criteria set out in
the Regulations;
the Quality Account is not consistent in all material respects with the sources specified in the
NHS Quality Accounts Auditor Guidance 2012/13 issued by the Audit Commission on 25
March 2013 (“the Guidance”); and
the indicators in the Quality Account identified as having been the subject of limited
assurance in the Quality Account are not reasonably stated in all material respects in
accordance with the Regulations and the six dimensions of data quality set out in the
Guidance.
We read the Quality Account and conclude whether it is consistent with the requirements of the
Regulations and to consider the implications for our report if we become aware of any material
omissions.
We read the other information contained in the Quality Account and consider whether it is materially
inconsistent with:
Board minutes for the period April 2012 to April 2013;
papers relating to the Quality Account reported to the Board over the period April 2012 to
April 2013;
feedback from the Commissioners dated 12 June 2013;
feedback from Local Healthwatch dated 20 May 2013;
the latest national patient survey dated 27 March 2013;
the latest national staff survey dated 14 December 2012;
the Head of Internal Audit’s annual opinion over the trust’s control environment dated 25
June 2013;
the annual governance statement dated 4 June 2013;
Care Quality Commission quality and risk profiles dated 28 February 2013; and
the results of the draft Payment by Results coding review dated April 2013.
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We consider the implications for our report if we become aware of any apparent misstatements or
material inconsistencies with these documents (collectively the “documents”). Our responsibilities do
not extend to any other information.
This report, including the conclusion, is made solely to the Board of Directors of
Hinchingbrooke Health Care NHS Trust in accordance with Part II of the Audit Commission
Act 1998 and for no other purpose, as set out in paragraph 45 of the Statement of
Responsibilities of Auditors and Audited Bodies published by the Audit Commission in March
2010. We permit the disclosure of this report to enable the Board of Directors to demonstrate
that they have discharged their governance responsibilities by commissioning an independent
assurance report in connection with the indicators. To the fullest extent permissible by law,
we do not accept or assume responsibility to anyone other than the Board of Directors as a
body and Hinchingbrooke Health Care NHS Trust for our work or this report save where
terms are expressly agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement under the terms of the Audit Commission
Act 1998 and in accordance with the Guidance. Our limited assurance procedures included:
evaluating the design and implementation of the key processes and controls for
managing and reporting the indicators;
making enquiries of management;
testing key management controls;
limited testing, on a selective basis, of the data used to calculate the indicator back to
supporting documentation;
comparing the content of the Quality Account to the requirements of the Regulations;
and
reading the documents.
A limited assurance engagement is narrower in scope than a reasonable assurance
engagement. The nature, timing and extent of procedures for gathering sufficient appropriate
evidence are deliberately limited relative to a reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial
information, given the characteristics of the subject matter and the methods used for
determining such information.
The absence of a significant body of established practice on which to draw allows for the
selection of different but acceptable measurement techniques which can result in materially
different measurements and can impact comparability. The precision of different
measurement techniques may also vary. Furthermore, the nature and methods used to
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determine such information, as well as the measurement criteria and the precision thereof,
may change over time. It is important to read the Quality Account in the context of the criteria
set out in the Regulations.
The nature, form and content required of Quality Accounts are determined by the Department
of Health. This may result in the omission of information relevant to other users, for example
for the purpose of comparing the results of different NHS organisations.
In addition, the scope of our assurance work has not included governance over quality or
non-mandated indicators which have been determined locally by Hinchingbrooke Health Care
NHS Trust.
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to
believe that, for the year ended 31 March 2013:
the Quality Account is not prepared in all material respects in line with the criteria set
out in the Regulations;
the Quality Account is not consistent in all material respects with the sources specified
in the Guidance; and
the indicators in the Quality Account subject to limited assurance have not been
reasonably stated in all material respects in accordance with the Regulations and the
six dimensions of data quality set out in the Guidance.
Rob Murray
Ernst & Young LLP
Cambridge
26 June 2013
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Appendix 3 - Statement of directors’ responsibilities in respect of the Quality
Account
The directors* are required under the Health Act 2009 to prepare a Quality Account for each financial
year. The Department of Health has issued guidance on the form and content of annual Quality
Accounts (which incorporates the legal requirements in the Health Act 2009 and the National Health
Service (Quality Accounts) Regulations 2010 (as amended by the National Health Service (Quality
Accounts) Amendment Regulations 2011).
In preparing the Quality Account, directors are required to take steps to satisfy themselves that:
• the Quality Account presents a balanced picture of the trust’s performance over the period
covered;
• the performance information reported in the Quality Account is reliable and accurate;
• there are proper internal controls over the collection and reporting of the measures of performance
included in the Quality Account, and these controls are subject to review to confirm that they are
working effectively in practice;
• the data underpinning the measures of performance reported in the Quality Account is robust and
reliable, conforms to specified data quality standards and prescribed definitions, and is subject to
appropriate scrutiny and review; and
• the Quality Account has been prepared in accordance with Department of Health guidance.
The Chief Executive as the Accountable Officer of the Trust and the Executive directors confirm to the
best of their knowledge and belief they have complied with the above requirements in preparing the
Quality Account.
The Trust Board in fulfilling its public accountability obligations confirm to the best of their knowledge
and belief that the Quality Account complies with the above requirements.
By order of the Board
NB: sign and date in any colour ink except black
Mr Hisham Abdel-Rahman
Chief Executive & Clinical chairman
. .....
th
Liz Pointing
Director of Nursing, Midwifery and Quality
th
Ms Jenny Raine
Director of Finance
Date...27 June 2013.................
..............................Date...27 June 2013...............
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Mrs Cara Charles Barks
Chief Operating Officer
Mr Paul DaGama
Director of Human Resources
Mr Mike Burrows
Chairman
Mr John Pye
Non Executive Director
Dr Jill Challener
Non Executive Director
* During 2012-13 the Trust has undergone a significant change in its governance arrangements. This
has been driven by the procurement process known as “Hinchingbrooke Next Steps” which resulted
in the commencement of an operating franchise on 1st February 2012. The franchise is regulated by a
franchise contract to which the NHS Midlands and East Strategic Health Authority, the Trust and the
franchise partner, Circle, were co-signatories.
A new Trust Board was also appointed from 1st February 2012, which consists of three Non-executive
Directors one of whom is the Trust Chair. The Board has reserved functions as set out in the Franchise
Agreement and the Intervention Order. This includes fulfilling the Trust’s public accountability
obligations as set out in Schedule 8 of the Franchise Agreement, Part 2 Reserved Matters, paragraph
2 (c).
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