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. -2- 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. -3- 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 -4- 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” -5- 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 -6- 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. -7- 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: -8- "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. -9- 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 - 10 - 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. - 11 - 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. - 12 - 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. - 13 - 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. - 14 - 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 - 34 - 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. - 38 - 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 - 51 - 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. - 52 - Appendix 1 Electronic Links Business plan 2012/2013 2012 2013 hinchingbrooke 16 point plan.pdf Business plan 2013/2014 Hinchingbrooke 16 point plan.pdf - 53 - 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 - 54 - 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. - 55 - 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. - 56 - 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 - 57 - 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 - 58 - 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............... - 59 - 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). - 60 -