We Care. We Excel. We Innovate. ALWAYS
Mid Essex Hospital Services NHS Trust - Quality Accounts 2012 | 13
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We Care. We Excel. We Innovate. ALWAYS
Mid Essex Hospital Services NHS Trust - Quality Accounts 2012 | 13
Contents
01
Chief Executive’s statement
Declaration of Accuracy
4
02
Quality structure and
accountabilities
7
03
Statements about the quality
of services
8
04
Review of the year
18
05
Looking back to 2012/13: a
summary of our achievements
29
06
Review Quality Performance:
Other quality indicators
34
07
Looking forward to 2013/14:
priorities for improvement
49
08
The Way Forward
51
09
Auditors Limited
Assurance Report
54
Annex A: Participation in
clinical audit
58
Annex B: Comments from
partner organisations
69
Annex C: Statement of Directors’
responsibilities in respect of the
Quality Accounts
72
Glossary of Terms
73
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01 - Chief Executive’s statement
Declaration of Accuracy
Welcome to Mid Essex Hospital Services Trust Quality
Account for 2012/13. I would like to thank all those who
have influenced and contributed to this Quality Account.
We have tried to make this account as easy a read as
possible however, there is some technical language
used.
To assist you we have included a glossary at the back
of the report that provides a useful guide.
Chief Executive’s Statement on Quality
I hope you find this Annual Quality Account useful in showing how
we performed in 2012/13 and what our priorities are for the next
12 months. Our Quality Account is aligned to Mid Essex Hospital
Services five year strategic vision which underpins all we do.
Malcolm Stamp CBE
Chief Executive
Our mission is to Care, Excel, Innovate by:
Strategic Priority 1 – Clinical and Service Excellence
At the very core of what we do are our patients. Our patients will experience high quality,
responsive care from our staff, who understand their needs and constantly strive to meet their
expectations. MEHT will be known for its innovative approach to delivery of the best possible
care, so that patients can receive the best of modern treatment in a compassionate, caring and
safe environment. Clinical excellence will be matched by service excellence and delivery.
Strategic Priority 2 – Quality Leadership
MEHT will be an organisation that is characterised by high-performing leaders at all levels who
motivate staff to achieve the best they possibly can for the patients in their care and the
community they serve. Under a strong and focused leadership, MEHT will ensure that decisionmaking, teamwork, learning and innovation are harnessed to create a hospital renowned for its
innovation, care and excellence.
Strategic Priority 3 – Effective Relationships
MEHT will be a significant partner with its local community and the wider health sector in order
to deliver the best possible healthcare in the most effective way. MEHT will look for partnerships
within the region, country, and further afield, which can enhance the quality of care and service
delivery that we achieve for users of the Trust’s services.
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Strategic Priority 4 – Business Excellence
ensure good understanding of the quality of
services we are offering. We recognise that
having a relative in hospital usually impacts
on the family around them and they may also
require support.
MEHT will have a reputation for superb
performance, managing its physical and
financial assets in such a way as to underpin
high-quality services and to allow investment
in the best care available for its patients and
community. Running an efficient business,
with best practice in our governance and
management, is the goal that underpins
our success as a top performing provider of
healthcare.
MEHT strategy aims to ensure we are
focused in improving the care we give and as
part of this last year we focused on a number
of specific quality measures we believed
would make a significant difference to the
experience of the majority of our patients.
These measures were:
• Improving the management of the
deteriorating patient
• Minimising the incidence of patient falls
and the severity of harm caused
• Reduce the incidence of hospital
acquired pressure ulcers
• Reduce the incidence of catheter
acquired infection
• Improve the prevention and
management of Venous
Thromboembolism (VTE)
I am proud of the work we have undertaken
in these areas. These are discussed in more
detail later in this Quality Account.
We have strengthened our Patient
Engagement and Experience team to focus
on the experience of patients and their
friends and family when visiting our Trust.
Our engagement team is being led by a
Director incorporating Patient Involvement,
PALS and Complaints, and also includes
the team for Spiritual Care and volunteers.
We work closely with our Patient Council to
The work of the Patient Engagement
and Experience team includes projects
to enhance patients experience and the
environment in which patients are cared for.
In the last 12 months this has included work
to improve the information on ward notice
boards, improving way finding at the Trust
and supporting mealtimes with volunteers
to assist in ensuring good nutrition and
hydration and companionship for inpatients.
The Trust Board are actively involved in
this work and frequently undertake walkarounds to all areas of the Trust, visiting
wards and service areas unannounced to
see and hear from patients themselves the
quality of care being provided. We also have
Patient Stories at every Trust Board so the
leadership team can hear first-hand about
the experiences of patients.
The Trust is also keen to know the opinions
of our patients and local community and we
monitor both social media and local media
outlets to understand opinions. We have a
strong Patient Council that recruited new
members this year and several thousand
Foundation Trust members.
We communicate regularly with our local
MPs, LINKS and Health and Overview
Scrutiny Committee and the newly formed
HealthWatch. We are pleased to report
that during the year we offered all inpatients
the opportunity to answer a survey telling us
about their stay at MEHT.
The results for the year placed the Trust in
the top quartile of trusts for friends and family
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that would recommend the ward or service
where they were cared for at the Trust. As
part of a national NHS roll out of the Friends
and Family Test from April 1st 2013 the
Trust will also make this survey available to
all visitors in A and E with newly positioned
kiosks.
We will continue to drive further
improvements in the areas identified in
the 2012/13 Quality Account. For 2013/14,
following consultation with our patients and
stakeholders, we have chosen another four
areas to prioritise:
• To improve patient safety
• To reduce hospital acquired infections
in line with national and local targets
• To improve clinical outcomes and
effectiveness
• To continuously improve the experience
of service users and their families and /
or carers
As a result of listening to our patients, visitors
and local communities we are working on a
new Travel Strategy for 2013/14 to improve
access and car parking to the site and we
are focused on sustainability as part of our
corporate responsibility to reduce carbon
emissions.
2012/13 was a challenging year, but a
year with significant quality improvements.
Particular progress has been made in
respect to quality of care and performance
of our services – MEHT has achieved a
transformation in quality and service delivery
performance, resulting in the Trust being
recognised as the top performing District
General Hospital in the East of England and
Midlands Strategic Health Authority region.
The Trust has also been the first in the
country to gain the nationally recognised
Quality Standard ISO 9001, for our theatres
and anaesthetics. The whole system is
driven to continually improve the quality of
care our patients receive.
The year built upon the previous year
of proactive change at the Trust, when
important leadership roles were put back in
the hands of our clinical staff, and service
provision was restructured, to ensure that the
resulting new pathways, delivered the best
possible patient care at all times.
There is no doubt it has been a difficult year
with the need to deliver improved quality of
our services against a backdrop of financial
challenges. We are committed that any cost
improvements we make are assessed
and approved by our Chief Nursing Officer
and Chief Medical Officer to ensure no
detrimental impact to the quality of care we
provide our patients. We know the next 12
months will bring more changes to the NHS
as many new organisations start their first
year as statutory bodies within the NHS.
MEHT will need to show leadership and
focus to ensure the quality of our services
continues to improve and ensure we have
the right NHS services for the people of
Essex for the future.
I hearby state that to the best of my
knowledge the information contained within
the Quality Account is accurate.
Malcolm Stamp CBE
Chief Executive
MEHT NHS Trust
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02 - Quality structure and accountabilities
This Quality Account describes the actions
that Mid Essex Hospital Services Trust
(MEHT) has put in place to improve the
quality of services we provide. The Trust
has developed a number of mechanisms
and sources for determining its key priorities
for improving the quality and safety of care
provided; this includes review of a range
of national and local indicators that reflect
the three domains of quality: Patient safety,
Clinical effectiveness, Patient experience.
• progress with quality issues we
prioritised for the period April 2012 to
March 2013;
• other quality indicators including a core
set of quality indicators developed by
the Department of Health;
• the quality issues to be prioritised
during 2013/14; and
• feedback on what others say about us.
Addressing the identified quality agenda is
monitored and supported by clinical leads
and relevant subgroups which report directly
to the Patient Safety Group which in turn
reports to the Patient Safety and Quality
Committee.
In completing this Quality Account we have
drawn on the input and experience of our
clinicians, nurses, patients, commissioners
and stakeholders.
The purpose of this Quality Account is to
provide an update to our patients, the public,
our staff and our partners on the following:
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03 - Statements about the quality of services
This section of the Quality Accounts is
prescribed by regulation. It provides a series
of mandated statements from the Board
which directly relate to the drive for quality
improvement.
The statements provide assurance in three
key areas:
• Our performance against essential
standards and the delivery of
high quality care, for example our
registration status with the Care Quality
Commission (CQC).
• Measuring our clinical processes and
performance, such as participation in
national clinical audit.
• Providing a wider perspective of how
we improve quality, for instance through
recruitment in clinical trials.
Review of Services
The Trust employs almost 4,000 staff and
provides services from sites in and around
Chelmsford, Maldon and Braintree. The main
site is Broomfield Hospital in Chelmsford
which has undergone redevelopment as part
of a £163m development financed under a
Private Finance Initiative (PFI) enabling the
centralisation of the vast majority of services
on the Broomfield site.
During April 2012 to March 2013 MEHT
provided, and occasionally sub-contracted,
a wide range of NHS healthcare services.
MEHT carries out a variety of reviews of
data available to them on the quality of care
in these NHS healthcare services, such as
patient, carer and staff surveys, national &
local clinical data and complies with regularly
updated policies that direct the methods of
operating these NHS services.
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Information about the quality of services
is obtained from a range of sources that
provide a framework to address the three
domains of quality: patient safety, clinical
effectiveness and patient experience.
Important elements of this framework
within the Trust are the Infection Prevention
and Control audit programme, the weekly
Potential Harm audits and the monthly
Patient Safety and Quality Dashboard, all
of which enables Board to Ward awareness
of quality performance underpinned and
informed by review and action planning at
service level. Other external and internal
sources of information on the quality of Trust
services are described below.
Goals agreed with commissioners
Commissioning for Quality and Innovation
(CQUIN) is an agreed quality improvement
scheme designed to reward ambitious and
continuous quality improvement across
an organisation or service. The CQUIN
scheme comprises a collection of quality
improvement goals that are agreed between
the commissioner, NHS Mid Essex, and each
provider on an annual basis.
A proportion of Mid Essex Hospital Services
income in 2012/13 was conditional on
achieving the agreed CQUIN goals. The total
incentive available for the schemes is 2.5%
of the Trust’s contract value outturn on top
of the Trust’s income, equivalent to around
£4.6m.
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The table below shows the goals within the 2012-13 CQUIN schemes:
Indicator Name
Description of Goal
VTE (venous
thromboembolism)
Prevention
• To achieve 95% or above of adult admissions to hospital
having a VTE risk assessment completed using the
clinical criteria of the national tool.
• To demonstrate 90% Q1-3 and 95% in Q4 compliance
with receiving appropriate prophylaxis as VTE risk
assessment indicated.
National Patient
Experience
• Improve responsiveness to personal needs of patients by
a target of 4 points on 2011/12 scores of 66.9.
Dementia
• To achieve 90% of all patients aged 75 and over
admitted to hospital as an emergency that have been
screened within 72 hours of admission using step 1 of the
Dementia screening tool.
• To achieve 90% of investigations for those patients who
have been identified as at risk of dementia from the
dementia assessment tool in (Step 2).
• To achieve 90% of onwards referral for those patients
in Step 2 who were assessed and had an outcome of
‘positive’ or ‘inconclusive’ (Step 3).
• To implement the Butterfly scheme Trust wide.
NHS Safety Thermometer
• To complete monthly surveying of all appropriate patients
(as defined in the NHS Safety Thermometer guidance) to
collect data on 4 outcomes (pressure ulcers, falls, Urinary
Tract Infection in patients with catheters and VTE) and
upload information onto the national database.
Regional Net Promoter
• To establish the Net Promoter Score question and report
for 10% of inpatient discharges with patients surveyed
within 48 hours of discharge.
• To evidence weekly reporting of the Net Promoter score
and Monthly Board meeting minutes.
• To improve the Net promoter score by 10 points from
agreed baseline figures.
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Indicator Name
Description of Goal
Pressure ulcer reduction
and elimination
To measure, each month all grades 2, 3 and 4 pressure ulcers
and indicate a zero tolerance approach to all avoidable grade
2, 3 and 4 pressure ulcers.
Deteriorating patient
Maternity Service Quality
Focus (year 2)
To improve patient experience and outcomes in Maternity
services by using newly developed data systems to monitor
current performance in real time, at individual patient level, to
identify and target appropriate interventional efforts.
Discharge Planning
To ensure that discharge planning process begins on
admission with patients given a recorded Estimated Date of
Discharge (EDD) (75% to be assigned an EDD within 24 hours
of admission by end April 2013), underpinned by staff trained
with knowledge of appropriate referral routes and achieve
streamlined discharge processes.
Medicines Management
Breastfeeding
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• To achieve 90% of appropriately assigned Patient At
Risk scores with 95% escalated by ward staff in line with
MEHT policy, with medical response documented.
• To achieve 95% of all unplanned admissions to ICU with
a root cause analysis completed.
• To achieve 80% of existing HCAs (Health Care
Assistants) and 100% of new HCAs to be assessed as
competent in the recording of observations and PAR
scores.
• To complete agreed audits and improvement plans
to ensure effective processes are in place for safe
prescribing of anticoagulants.
• To promote the New Medicines Service for patients
who have been newly diagnosed with Asthma, Chronic
Obstructive Airways Disease, Hypertension, Type 2
Diabetes or antiplatelet/anticoagulant therapy to their
community pharmacy,
• To reduce gastrointestinal events and cardiovascular
events from NSAID usage. The aim is to reduce the use
of Diclofenac, this will be monitored by quarterly audits.
To increase the percentage of preterm babies who are fed on
mother’s breast milk at discharge.
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Indicator Name
Description of Goal
Home Therapy Renal
Dialysis
Main Renal Unit to achieve a minimum of 35 patients receiving
home therapy dialysis by April 2013. This includes patients
receiving peritoneal dialysis (including assisted automated
peritoneal dialysis) and minimum percent of patients receiving
home haemodialysis.
Pre-emptive Renal
Transplant
To increase number of patients who are suitable for transplant
to receive their transplant prior to starting dialysis (pre-emptive)
Renal Patient View
For Main Renal Units to actively encourage the use of Renal
Patient View during nephrology outpatient attendance and
to actively offer the choice of patients with Chronic Kidney
Disease to access Renal Patient View
Clinical Dashboard
To implement the routine use of specialised services clinical
dashboards
To assess the number of patients who are not able to be
Recording of specific
admitted due to the lack of clinically appropriate bed.
information where a
patient is not admitted due
to a lack of availability of a
clinically appropriate bed
Assessment of the
implementation of the
psychosocial training tool
for adults and children
• To assess the implementation of the training tool
developed to improve the psychosocial care that burns
patients receive within the burns services.
• Identification and implementation of actions to ensure
80% compliance by all permanent members of the MDT
involved in providing burn care by 31st March 2013 (with
a plan in place to demonstrate achievement of 100%).
Reduction in the average
length of stay of patients
within the Burns Service
• To assess the average length of stay (by TBSA and age)
for patients within the Burns Service.
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At the time of publication the Trust’s
achievement against these challenging
and valuable goals has not yet been
fully realised. However, the Trust’s own
assessment is that it has achieved up to
been agreed by the CCG as 86% of the
value.
An example of progress and achievement
of CQUIN relates to the Net Promoter score
where the baseline figure submitted in May
2012 was 60%, with a response from 24%
of patients discharged. This score has now
improved to 83% with coverage of 35%.
This success is due to a number of factors
including our collective drive for improvement
across all clinical areas, implementation of
weekly performance reports and free text
feedback from patients which is directly
sent to the ward staff to act upon and make
changes as deemed appropriate. The Trust
have incorporated the national patient
experience questions into the friends and
family test questionnaire, this has enabled
the Trust to have ‘real time’ information.
Already the Trust has made changes to the
discharge letters and medication information
upon discharge based on comments and
feedback received from our patients.
Another success story for the Trust is the
implementation of the Dementia diagnostic
tool and Butterfly Scheme designed to
support the care of patients with Dementia
and their carers. The Trust has 26 identified
champions and another 36 link nurses ready
to take the Butterfly scheme forward. A
number of different projects are underway
to support environmental changes to ensure
MEHT is working towards been a dementia
friendly hospital. Different levels of staff
training will be launched along with an IT
system upgrade to support the introduction of
an electronic assessment tool.
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Details of the CQUINs for 2013/14 will be
made available via the Trust Internet site.
Data quality
Good quality information underpins the
effective delivery of patient care and is
essential if improvements in quality of care
are to be made. Improving data quality,
including the quality of ethnicity and other
equality data, will thus improve patient care
and improve value for money.
The Indigo4 Data Quality Report shows
the percentage of records in the published
data which included the patient’s valid NHS
number (for November 2012 Freeze) was:
• 100% for admitted patient care
• 99.8% for outpatient care
• 97% for accident and emergency care
The Indigo4 Data Quality Report shows the
percentage of records in the published data
which included the patient’s valid General
Medical Practice Code (for November 2012
Freeze) was:
• 100% for admitted patient care
• 100% for out patient care
• 100.% for accident and emergency care
The Information Governance Group (IGG)
and Business Information Group (BIG) are
the vehicles for taking forward the data
quality agenda, with the IGG taking the
strategic decisions needed to improve data
quality and reporting directly to the Patient
Safety and Quality committee of the Board.
The BIG is the operational group that
monitors data quality every two months and
prioritises the tasks to improve data quality
and establish best practice. Monitoring and
performance of progress is addressed in the
action plan relating to the BIG and through
the IG Training Strategy.
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The main data quality drive during 2012/13 was to improve the coverage of NHS Numbers
through improving completeness and accuracy of patient demographic data. This was done via
both front line staff who came into contact with patients and via validation reports from support
functions.
Clinical Coding Errors
MEHT was subject to the Payment by Results clinical coding audit during 2012/13 by the Audit
Commission. The final report stated the error rates for diagnoses and treatment coding were:
In the case of Chemotherapy the issue with the Primary Procedures had already been
identified and rectified prior to the Audit. Complex Pain and Urology concerns have since been
addressed.
The accuracy results confirm that the Trust has maintained its Level 2 Information Governance
Toolkit Attainment Level.
Information Governance
In March 2012, the Trust submitted an IG Toolkit score of 70%. The planned submission for
March 2013 is approximately 73% which equates to a GREEN assessment but requires all
criteria to be met at a minimum of Level 2.
The most important criteria for the Trust relates to IG Training. Since April 2011, all staff have
received, and continue to receive on commencement with the Trust, a copy of the IG Handbook
which highlights all the key points from all the IG and IT security policies to assist them in their
day to day working.
In June 2012 it was identified that to a achieve 95% of staff trained by March 2013 would require
a new training strategy utilising every possible approach to achieve the target. During the period
July-September 2012, over 1000 trust staff were trained either at bespoke sessions, clinical
mandatory update or by undertaking on line training. We are expecting that by continuing with
the combination of training routes that the March target will be achieved.
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2012/13 has been a year of consolidation
following the introduction of the new IG
structure which has worked effectively
and now oversees all the Risk Assurance
Frameworks, not just relating to IG, but also
the IT aspects of IG and Medical Records.
This work is supported by the introduction of
electronic incident reporting system which
has improved the levels of reporting and
investigation and enhanced organisational
learning from incidents falling within the
framework of Information Governance.
The Trust has not reported any incidents to
the Information Commissioners Office (ICO)
and no complaints have been received about
the Trust to the ICO Office.
Participation in Clinical Audits
Clinical audit is an important quality
improvement process for the Trust. By
participating in relevant national audits, we
can compare our practice with other similar
organisations and identify whether we
need to improve the services we provide.
In addition, we encourage all of our clinical
areas to perform local audits to measure the
quality of patient care they provide.
Participating in relevant national clinical
audits and confidential enquiries provides
an important opportunity for the Trust to
benchmark the quality of its services against
those of other providers and to improve
services where deficits are identified.
During the period from April 1 2012, to March
31 2013, there were 35 national clinical
audits and 3 national confidential enquiries
that covered NHS services that Mid Essex
Hospital Services Trust provides. During that
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period, the Trust participated in 83% of the
national audits and 100% of the confidential
enquiries it was eligible to participate in.
The national clinical audits and national
confidential enquiries that Mid Essex Hospital
Services Trust was eligible to participate in
during the period are listed in Annex A, table
1.
When national clinical audit and confidential
enquires are published, clinical leads will
review the findings. By taking account of
such reports the Trust can identify what it
does well and what can be improved. The
reports of 22 national clinical audits and 1
National Confidential Enquiry were reviewed
by the Trust during the period April 2012 to
March 2013 and the learning and actions that
the Trust has taken to improve the quality of
the care provided are detailed in Annex A,
table 2.
Local clinical audit provides an opportunity
for comparing the quality of the services
the Trust provides against best practice.
The reports of 11 local clinical audits were
reviewed by the Trust and table 3 in annex A
identifies the actions that the Trust has taken
to improve the quality of healthcare provided.
Participation in clinical research
The profile of clinical research has been
raised as part of the Government’s plan
for growth (2011), with an aim to facilitate
access to the UK’s clinical research
infrastructure and generate wealth. Mid
Essex Hospital Services Trust Research &
Development Department (R&D) has the
capacity and resources to add value to the
research growth and increase innovation. As
part of the government’s plans for reform,
the department has been determined in
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raising the profile of R&D in the Trust, and
the Trust has recognised that it must always
hold responsibility for research governance.
As this is a specialist form of governance,
particularly as it is linked to patient safety
and complex legislation the R&D Department
has a dedicated R&D governance lead, Risk
Management and Governance Facilitators
and a robust system to ensure compliance
with the relevant legislations.
The number of patients receiving NHS
services provided or sub-contracted by
MEHT in the period 1st April 2012 to
March 2013 that were recruited during that
period to participate in National Institute for
Health Research (NIHR) adopted research
approved by a research ethics committee
was 471.
MEHT is committed to ensuring financial
probity and the NIHR costing templates
are audited monthly by the Comprehensive
Local Research Network finance team as
well as being peer-reviewed. As part of
our commitment to home-grown research,
the Trust has sponsored 9 projects, and
conducted an internal audit on all Trust
sponsored projects, with recommendations
to the investigators as part of our governance
policy.
In the last 12 months, 39 publications have
resulted from our involvement in healthcare
research, which shows our commitment to
transparency and desire to improve patient
outcomes and experience across the NHS.
Participation in clinical research
demonstrates the Trust’s commitment to
improving the quality of care we offer and
to making our contribution to wider health
improvement. Our clinical staff stay abreast
of the latest possible treatment possibilities
and active participation in research can lead
to successful patient outcomes.
MEHT was involved in conducting 59 NIHRadopted clinical research studies, open to
recruitment, during 2012/13. 21 of these 59
studies were new projects approved during
2012/13 and a further 80 study amendments
were approved. There were 27 Principal
Investigators leading multidisciplinary
research teams in studies approved by a
research ethics committee during 2012/13.
These staff participated in research covering
15 specialties.
The most research active areas at MEHT
are: oncology, public health, rheumatology,
renal, stroke, burns & plastics.
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Care Quality Commission
Mid Essex Hospital Services NHS Trust registered with the Care Quality Commission (CQC)
on the 01/04/2010. The current registration is for the following regulated activities at these
locations.
Locations
Broomfield Hospital
Regulated Activities
• Assessment or medical treatment for persons detained
under the Mental Health Act 1983
• Diagnostic and screening procedures
• Family Planning
• Maternity & Midwifery Services
• Surgical Procedures
• Termination of Pregnancies
St Michael’s Health
Centre
Maternity & Midwifery Services
St Peter’s Hospital
Maternity & Midwifery Services
The CQC undertake unannounced
inspections of all healthcare provider
organisations to ensure that the needs of
patients are met. In the 12 month period to
March 2013, the Trust has had a number
of visits from the CQC which have raised
various concerns:
• The CQC visited the Trust to undertake
an unannounced inspection in
April 2012 to review progress on
concerns raised during a previous
visit (December 2011). As a result,
they removed two concerns relating to
Outcome 11 (Safety, availability and
suitability of equipment) and Outcome
13 (Staffing) but concluded that the
minor concern relating to Outcome 5
(Meeting Nutritional Needs) should
remain.
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• Following a further visit in April 2012,
the CQC imposed a ‘Warning Notice’
on the Trust in relation to Outcome 21
(Records) and declared a moderate
concern. This warning notice and
moderate concern was removed
following a return visit in July 2012.
• The CQC declared a minor concern
with Outcome 4 (Care & Welfare
of people who use the services),
in relation to inconsistencies in the
documentation of patient assessment
and treatment plans. In developing a
response to these issues, the Trust
provided intensive support to the
wards to improve nurse leadership
and enhance professional practice and
nursing documentation templates were
fundamentally revised following a Trustwide review.
• The CQC carried out an inspection
in February 2013 to review progress
and as a result the concern relating to
Outcome 5 (Meeting Nutritional Needs)
was removed. However during this
visit further concerns were raised in
relation to Outcome 4 (Care & Welfare
of people who use the service) resulting
in a Moderate concern being raised and
a Warning Notice being imposed with
a requirement to be compliant by the
31 May 2013 and a moderate concern
in relation to Outcome 9 (Management
of Medicines). As a result of this latest
inspection and the findings, a detailed
action plan has been developed and
is being progressed. It is of note that
whilst there were clearly issues with the
quality of the documentation for those
patient records reviewed, the direct
patient feedback was overwhelmingly
positive.
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04 - Review of the year
Whilst being a period of significant
transition and change, 2012/13
has overall been a very successful
year for the Trust in relation to
the clinical quality, patient safety,
performance delivery and sustainable
transformational improvement.
Despite financial pressure and an increasing
number of patients seen in the past year the
Trust continues to ensure that patient safety
and quality of service is the number one
priority.
The outcomes have been very encouraging
and reflects the leadership, energy and
commitment of the Board and staff in rising
to these challenges. As a result the Trust
is again one of the best District General
Hospitals in the East of England and the
Midlands.
During the course of 2012/13 the Trust
has also been in the spotlight through the
excellent clinical quality of services and the
innovation of the departments in providing
their expertise and patient care.
Below are a number of the innovations and
good news that came out of the Trust in
2012/13.
April 2012
Mum’s thanks to hospital staff for saving
‘miracle baby’
A Witham woman praised the staff at
Broomfield Hospital’s maternity unit after
their swift action saved the life of her newborn child – dubbed ‘miracle baby’ by nurses.
Chinese takeaway, but a few hours later she
was involved in her own real-life drama.
Louise’s dramatic tale began when she
became concerned by the lack of movement
of her baby, with just five weeks to go
until it was due. She went to Broomfield
Hospital where she was examined and tests
confirmed she was right to be concerned.
She underwent an emergency caesarean
under general anaesthetic as there was no
time for epidurals to take effect. “When I
came round, I was told my baby’s condition
was critical. I couldn’t take it all in – it
seemed like it was happening to somebody
else and I was watching the situation unfold.
It was my first pregnancy and nothing had
prepared me for this,” said Louise.
Baby Olivia’s problem was she had been
born with a haemoglobin (the protein
molecule in red blood cells) level of only
three, when it should have been around
18. Within two hours of being born, she
underwent an emergency blood transfusion.
Within 48 hours, she underwent a further
blood transfusion as her life hung in the
balance.
Sharon Pilgrim, advanced neonatal nurse
practitioner in attendance at the birth,
said in 20 years in the job, she had never
known such low haemoglobin levels. “It
was a miracle she survived. She was
incredibly pale when born and had difficulties
breathing.”
A year on, Olivia is in fine health with no
long-term problems from the drama.
Mum Louise Bearman was looking forward
to watching The X Factor accompanied by a
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Mid Essex Hospital Services NHS Trust - Quality Accounts 2012 | 13
May 2012
The Trust named as one of the CHKS 40
Top Hospitals 2012
Mid Essex Hospital Services NHS Trust was
one of the CHKS 40 Top Hospitals 2012.
Healthcare intelligence and improvement
services specialist CHKS (part of Capita)
announced the winners of its Top Hospitals
programme awards at a ceremony in
London, and the 40 Top Hospitals award was
one of several awards that were part of the
awards programme.
Cardiopulmonary Exercise Testing (CPET)
has become one of the ‘Gold Standard’ preoperative tests recently developed. This test
is able to assess the patients ability to deliver
oxygen to the body. Measuring this during
exercise gives a good indication of how a
particular patient would cope with major
surgery and the immediate post operative
period. This result allows for the planning of
specific care packages for during and post
operative procedure. These would include
interventions such as invasive monitoring
during surgery and planned intensive care
admissions post operatively.
As well as individual national awards for
patient safety, quality of care and data
quality, CHKS celebrates excellence
amongst its clients across the UK with the
40 Top Hospitals award. This award is based
on the evaluation of 23 key performance
indicators covering safety, clinical
effectiveness, health outcomes, efficiency,
patient experience and quality of care.
The test begins by entering the patient’s
details such as height, weight, sex and
age into a programme; this will then give
estimations of predicted physical capabilities.
The Chairman of Mid Essex Hospitals Trust,
Sheila Salmon, said:
July 2012
“Standards of healthcare are improving all
the time, so to be recognised as a top 40
hospital is a great achievement. I would
like to thank all the Trust’s staff for their
continued hard work.”
July 2012
‘Gold Standard’ Testing for CPET Patients
The body can sustain varying amounts of
trauma during major surgery pre-operative
assessment and cardiopulmonary exercise
testing is one of the best ways of assessing
the risk for the patient. This assessment
provides clinical teams the means to ensure
appropriate levels of care are provided for
the patient according to their preoperative
level of fitness.
Over 500 patients were tested last year and
surgical teams across the Trust found the
information extremely valuable in preparing
their patients for surgery.
Top Multi-Department Working Helps
Stroke Victims in Mid Essex
A stroke can have devastating effects for
a patient, every second a stroke goes
untreated, 32,000 neurons die.
As a stroke evolves over a period of 10
hours this will lead to the patient losing
approximately 1.2 billion neurons, equating
to ageing 3.6 years for every hour, a total of
36 years on average!
In mid Essex, the stroke team realised that
the best way to treat stroke patients in the
fastest possible way was to engage with
a number of consultants from the A&E,
radiology and medicine departments.
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Once a patient is brought into the emergency
department with a suspected stoke, they
are immediately assessed and treated by
a team that includes a stroke nurse, an
Operating Department Practitioner, a clinical
trainee in medicine, a radiographer and a
radiology/stroke consultant to make any final
decisions.
The results at the Trust using this multidisciplinary team approach have been
excellent. In the first 72 days using this new
pathway, 21 patients received thrombolysis.
July 2012
Broomfield Hospital gets top marks again
in PEAT inspection
Patient food at Broomfield Hospital again
received the highest rating of ‘excellent’ in
the annual 2012 PEAT (Patient Environment
Action Team) inspection.
These records hold limited, but essential
information about the patient being treated
including details of medicines and allergies
or previous adverse reactions to any
medicines taken.
This new system was introduced to ensure
the clinical pharmacy team at the Trust have
as much information as they can about the
medical needs of the patients they are caring
for.
When a patient is seen in an emergency
situation, or when the GP practice is closed,
this new electronic system comes into its
own, allowing instant access to these care
records for clinical staff working at the
hospital. This access ensures safe treatment
is given, taking into account the patient’s
current medication needs, and what drugs
can and can’t be administered.
This annual assessment is managed through
the NHS Information Centre and covers
NHS hospitals in England with more than ten
inpatient beds.
July 2012
The teams look at standards within three
main categories – environment, food, and
privacy and dignity. Each category is given
a rating of ‘excellent’, ‘good’, ‘acceptable’,
‘poor’ or ‘unacceptable’. This year Broomfield
hospital scored ‘excellent’ for the quality of
the patient’s food and ‘good’ for the Hospital
environment and patient privacy & dignity.
The ancient woodlands within Pudding Wood
and the ‘Long Shapely Belt’ that surround the
hospital site at Broomfield Hospital got an
exciting makeover following the award of a
£49,500 grant.
July 2012
Access to care records allows quicker
treatment for patients
Summary Care Records (SCRs) were
introduced at the Trust to improve the safety
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and quality of our patient care.
We Care. We Excel. We Innovate. ALWAYS
Patient Pathways benefits from Lottery
Funding
The grant, awarded by the Heritage Lottery
Fund, was allocated to the Trust to improve
the green spaces throughout the hospital
estate and the surrounding connecting
cycleways and pathways for patients, staff
and visitors.
The funds will bring long-term benefits for
all visitors to the hospital with new areas for
quiet and reflection being created alongside
improved access routes into the hospital.
The long term aim of the project will be the
Mid Essex Hospital Services NHS Trust - Quality Accounts 2012 | 13
sustainability of the natural woodland estate
and to encourage the understanding of this
historic environment by everyone that uses it.
Green open spaces are known to create a
positive environment of wellbeing for people,
and this is certainly the case for the many
patients and visitors who use the grounds
to discover the peace and tranquillity this
brings.
September 2012
July 2012
The Trust has over 400 volunteers who help
in many ways all around the hospital site,
manning help desks, assisting patients in
finding the way to their appointments, and
generally providing much needed support for
the organisation.
The Trust is one of a record breaking 1424
parks and green spaces that received a
Green Flag Award
Trust pays tribute to its loyal volunteers
Mid Essex Hospitals held a special event for
its many volunteers as a thank you for their
tireless work on behalf of the Trust and the
help and benefits they bring to our patient
care.
The Trust was one of a record number of
1424 UK sites receiving a Green Flag Award
this month – the national award for public
and community parks and green spaces.
Jonathan Wright, Patient Experience and
Volunteer Services Manager said:
The record number of sites receiving an
award this year ensures that even more of
us now have access to well-managed, highquality green spaces so important for health
and leisure activities.
“This was a great opportunity for the Trust to
say a big ‘thank you’ to the many volunteers
for all that they do to help the organisation,
and myseIf on a daily basis. I would like to
pay particular tribute to their work in helping
our patients during the new wayfinding
arrangements, assisting them in finding their
way around the hospital.”
Pudding Wood on the Broomfield Hospital
site in Chelmsford is an area of natural
beauty that allows patients, visitors and staff
the opportunity to relax and walk through a
tranquil environment, away from the busy
setting of a major acute hospital. Teams of
community and corporate volunteers give
their time to improve the site and this has
been a big factor in the Trust receiving this
award. Recent activity from local businesses
includes Inntel and Essex County Council
Trading Standards teams.
Two regular volunteers are Tim and
Margaret who are local residents. Tim said
“I am extremely proud that the woods have
received this accolade.”
September 2012
MEHT supports the Worlds Biggest
Coffee Morning
Mid Essex Hospitals supported the annual
Macmillan coffee morning in the main atrium
building at Broomfield Hospital with BBC
Essex Radio in attendance.
Apart from the coffee and cakes, which were
an outstanding success, the vital work and
support that Macmillan provides for the Trust
was highlighted.
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Mid Essex Hospital Services NHS Trust - Quality Accounts 2012 | 13
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As a cancer specialist centre for skin cancer
surgery, upper GI cancer surgery and head &
neck surgery the Trust is very supportive of
the excellent work of the charity and the work
of the Macmillan nurses.
Over the years the Trust has had 8 funded
Macmillan posts plus the Macmillan’s carers
project. The Trust’s very busy chemotherapy
unit has 6000+ treatments per year and
these are managed by a Macmillan funded
Clinical Nurse Specialist post.
marks out of 100 on each question.
Following a £1.5 million investment in
improving cancer services during the past 12
months, the Trust’s Lead Director for Cancer
Services, Mark Angus, believes this will
result in an even better experience for Mid
Essex patients in the future.
Among the many initiatives introduced in the
past year are:
• New service with consultant review of
patients within 24 hours of admission;
• Investment in a seven-day nurse-led
palliative care service;
• A daily patient flagging system, which
allows clinical teams to be informed
of patients who are admitted to the
hospital, who have a cancer diagnosis
or who have had chemotherapy in the
previous 6 weeks
• An electronic information prescription
project. Electronic prescribing for
chemotherapy is a key Improving
Outcomes Guidance (IOG) requirement
for the delivery of chemotherapy for
patients. This will hopefully be fully
implemented during next year.
Macmillan have supported a number of
posts over recent years including nurses
and doctors. They also provide an extensive
range of information and booklets for patients
and carers throughout their pathway of
care. The Trust is also fortunate to have
the Macmillan Carers project onsite, which
continues to provide invaluable support to
the carers of people with cancer.
The Macmillan Palliative Care team are
also extremely busy with over 3500 face to
consultations last year, these patients being
helped by three Macmillan funded post
holders.
October 2012
Cancer care £1.5 million investment
shows results for Mid Essex Hospitals
patients
The Trust was cited as being one of the
20 most improved Trusts in the country for
providing a positive experience for cancer
patients, following the 2011/12 Cancer
Patient Experience Survey.
The survey, undertaken by Quality Health on
behalf of the Department of Health, asked
patients who have used cancer services to
rate their experience. Each Trust is awarded
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November 2012
Phoenix Ward see the benefits for their
Children in Need
The Children’s Ward, Phoenix Ward,
were visted by the Laughter Specialists,
highlighting the benefits of Children in Need
funding, and how it impacts on local people.
BBC Radio Essex were also in attendance
to record for their listeners how laughter can
help our young patients.
The Laughter Specialists are entertainers
and performers who bring fun and laughter
to sick children in the hospital. Patrick
Mid Essex Hospital Services NHS Trust - Quality Accounts 2012 | 13
Jacobs and Annie Aris have many years of
experience working in the field of children’s
entertainment, having worked for many years
as clown doctors at Great Ormond Street
and Addenbrookes Hospitals and in special
needs centres, hospices, care homes and
hospitals.
They provide a whole range of distractions
for the children on the wards including
comedy, clowning, magic, songs, play
acting, music, puppets and most importantly
improvisation.
With their abilities of listening, patience,
awareness and acceptance they use their
artistic skills to enable laughter and fun for
the youngsters. Their experience in the
dramatic arts helps their performances
enourmously, and they have undergone
training in hospital procedures, infection
control, a range of physical and
psychological illnesses, ethics, child
protection, play and other related areas.
November 2012
StAARS in town for World Breast
Reconstruction Conference
An international Breast Reconstruction
Conference was hosted by St Andrew’s
Regional Burns and Plastics Centre at
Broomfield Hospital in partnership with
Anglia Ruskin University during November
2012. Speakers from around the world met
in Essex to debate the very best practices
in the field to enhance patient care. The
conference also hosted the launch of the
new partnership, StAAR.
This partnership, between the Postgraduate
Medical Institute (PMI) at Anglia Ruskin
University and the world renowned St
Andrew’s Centre is dedicated to the
investigation of novel therapeutic strategies
in plastic, reconstructive and burns surgery.
The aims of the co-operation are to focus
on regional research activity, to provide
an infrastructure to maximise funding, and
to create opportunities for training and
partnerships with industry. The clinical aims
are to increase the evidence base for current
practice and to provide a multidisciplinary
platform for regional, national and
international co-operation and to provide an
educational framework for clinical activity.
The conference, held at the university,
debated the latest clinical advancements in
breast reconstructive surgery. Speakers from
as far afield as China, Canada and America
gathered to talk about the very best
practices in this field of surgery.
The idea for this conference came from
Venkat Ramakrishnan, a local consultant
surgeon with an international reputation
for complex ‘microsurgical’ breast
reconstruction.
November 2012
St Andrew’s Anglia Ruskin research
highlights risk of burns from spontaneous
rupture of hot water bottles
New research – the first of its kind in Europe
– revealed the dangers associated with the
spontaneous rupture of hot water bottles.
Burn injuries resulting from hot water bottle
use is authored by Dr Shehab Jabir, Quentin
Frew and Professor Peter Dziewulski of the
St Andrews Anglia Ruskin (StAAR) Research
Unit.
StAAR is a partnership between Anglia
Ruskin University and the world-renowned
St Andrew’s Centre for Plastic Surgery
and Burns based at Broomfield Hospital.
The new research was officially launched
at Anglia Ruskin’s Postgraduate Medical
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Mid Essex Hospital Services NHS Trust - Quality Accounts 2012 | 13
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Institute in Chelmsford on Friday, 16
November 2012.
The study, which examined the case notes
of 50 patients with burns resulting from hot
water bottle use from between January 2004
and February 2012, found that exactly half
of all injuries were the result of the hot water
bottle bursting.
November 2012
Success for Mid Essex Woodland Project
during national tree week
Members of the Grounds and Garden team
at the Trust travelled to the Houses of
Parliament to pick up a highly prestigious
Gold award for the work in the woodlands at
Broomfield Hospital.
Pudding Wood is an area of ancient
woodland which has been improved
significantly for patients and visitor use over
the last few years. With help from the local
community, the Trust manages the woodland,
with a small team of volunteers, supported by
our grounds maintenance team, and assisted
by teams from a young people’s training
provider, Impact training, MENCAP, Intel and
Essex County Council.
The woodland has also been an inspiration
for environmental art used by degree
students from Writtle College, which has
given additional features for people to
enjoy using the natural materials from the
woodland floor.
The Green Apple award is recognition of the
achievement of the teams working together,
providing an accessible green space which
is used for quiet reflection at what could be a
stressful time, or as a “green gym” for
exercise.
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We Care. We Excel. We Innovate. ALWAYS
The grounds and gardens staff have been at
the heart of this project and deserve special
recognition for the way they have gone
above and beyond their daily workloads by
supporting volunteer activity, using waste
materials, and bringing invaluable physical
support and advice to the project.
The project also recognised the significant
social benefit of involving people from all
community groups to make this happen.
Volunteers were sought from a wide range
of community groups: MENCAP, our Parish
Council, Essex Council, students and
trainees from local training centres and
colleges and local business. All had
different reasons for volunteering which
included enjoying activities in the outdoors,
learning opportunities, health and fitness as
well as a being part of the team.
December 2012
Biomedical Team praised by auditor for
their expertise
The Biomedical Engineering Department
(BME) here at the Trust were awarded the
British Standards Institution (BSI) registration
ISO 9001:2008. This re-certification lasts
for the next three years and covers the
Quality Management System including the
maintenance and repair of all the Trust’s
medical equipment.
The Biomedical team are highly skilled
electromechanical technologists who ensure
that all medical equipment is safe, functional
and properly configured. They install, inspect,
maintain, repair, calibrate, modify and
design biomedical equipment and support
systems and ensure they adhere to medical
standard guidelines.
The BME team has been registered since
2000 and been audited by the BSI on an
annual basis, and this year saw its three
Mid Essex Hospital Services NHS Trust - Quality Accounts 2012 | 13
yearly renewal of the certificate audit. The
team passed with flying colours and the
auditor commented on the level of expertise
within the department. The department
consists of 11 members of staff and each
member of the team has a role to play in
maintaining the quality management system.
This accreditation is important to
demonstrate that the Trust is working to
all the quality standards, which ultimately
contributes to better patient care.
December 2012
Cardiac Services at the Trust among the
best in the country
The most recent report from the National
Heart Failure Audit Project, published
in November 2012, shows that Cardiac
Services at Broomfield Hospital achieved
some of the best results in the country for
the treatment of heart failure for patients. In
particular, the proportion of patients having
inpatient echocardiograms, and receiving
ACE inhibitor with beta blocker therapy was
very high.
Heart failure is an important medical
condition characterised by frequent hospital
admissions and poor outcomes. The use of
evidenced-based therapies has been shown
to increase life expectancy and reduce the
need for emergency hospital admissions.
Heart failure occurs when the heart is unable
to provide sufficient pump action to distribute
the blood flow to meet the needs of the body.
Common causes of heart failure include
myocardial infarction and other forms of
ischemic heart disease, hypertension,
valvular heart disease, and cardiomyopathy.
The National Heart Failure Audit Project was
set up in 2007 to monitor the care of patients
admitted to hospitals in England and Wales
and collects data based on recommended
clinical indicators. Using linked data from
the Office of National Statistics (ONS)
the National Audit project was able to
demonstrate large mortality reductions when
best clinical practice was followed.
January 2013
Mayor Opens New Sexual Health Clinic in
City Centre
The Mayor and Mayoress of Chelmsford
officially opened the new Sexual Health
Clinic at the Fairfield Centre in Chelmsford
on Thursday 17th January 2013.
The Genito-urinary medicine (GUM) team
had moved from their old location at the
Chelmsford & Essex Centre on New London
Road to the new development within the bus
station complex in the centre of the city.
Malcolm Stamp CBE, Chief Executive of the
Trust and Medical Director, Dr Ronan Fenton
accompanied the Mayor and Mayoress on
a tour of the new facilities along with senior
clinical staff and the consultant from the
GUM service.
Having moved from the old St John’s
Hospital site, to the lastest location at the
Chelmsford and Essex Centre in New
London Road, the unit is now in a very
accessible central location for patients, being
in the heart of the city which has excellent
links with public transport. The choice of
location recognises that accessible GUM
services are extremely important.
The work of the Genito-urinary service is
extremely important for the health of the
community. It treats and works to prevent
and control sexually transmissible infections
and by working closely with the Trust’s
partners a top quality service is provided.
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GUM services in the UK are recognised
across the world as the best model for
managing and preventing Sexually
Transmitted Infections (STIs), and last year
the unit in Chelmsford saw over 10,000
patients.
HIV services will also to be centralised
on to the site during 2013 and this will be
supported by the appointment of a new GUM
consultant.
January 2013
The Trust and Anglia Ruskin, both
StAARS that SHINE
The clinical collaboration between St
Andrew’s Centre at the Trust and Anglia
Ruskin (StARRS) continues to forge forward
in enhancing medical excellence following
the award of a grant by the Health
Foundation, an independent charity that
works to continuously improve the quality of
healthcare in the UK.
The Health Foundation’s annual Shine
programme seeks to support innovation
designed to improve quality of care, and it
provides healthcare teams with funding of up
to £75,000 to run and test innovative quality
improvement ideas.
Project teams develop their innovations
through activities such as innovation, change
management, measurement and selfevaluation.
The grant was awarded for a project that
looks at developing a rapid feedback system
to improve surgical outcomes. With any
surgical procedure, there is some risk of
complications, measuring the rates of these
complications is a key step in improving
patient outcomes.
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February 2013
Another Clinical First for the Trust
Top clinical performances since 2011 have
seen the Trust consistently retain a top 6
position in the East of England’s list of top
performing organisations, and another first
has been added.
Broomfield Hospital, one of three hospital
sites run by the Trust, is the first hospital
in the UK to be performing Xperguide
cryoablation in the treatment of kidney
tumours.
Kidney cancer is one of the most common
cancer types in the UK, with nearly 10,000
people newly diagnosed every year and
more than 4000 deaths caused by this
disease. Kidney cancer is becoming more
common and is often detected at an early
stage, before it is causing symptoms, due to
the increasing number of ultrasound, CT and
MRI scans that are now performed.
This form of cancer can be successfully
treated with conventional surgery but
some patients are too frail for surgery, or
have several tumours, which cannot all be
removed at surgery.
Ablation is a technique that kills cancer cells
with either extremely high or extremely low
temperatures. It is a “minimally invasive”
procedure with very low complication rates,
which can therefore be offered to patients
who are not fit enough for surgery.
Cryoablation involves placing narrow needles
directly into a tumour and then pumping
freezing gas through the needles to cause
very low temperatures within the tumour. An
ice ball grows around the tips of the needles,
which engulfs the tumour and kills the
cancerous cells. Renal tumour cryoablation
can be performed either under x-ray
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Mid Essex Hospital Services NHS Trust - Quality Accounts 2012 | 13
guidance or as a keyhole surgery procedure
depending on the position of the tumour
within the kidney.
Cambridge is the designated Level 1 Trauma
Unit.
Although a small number of other hospitals in
the UK perform kidney tumour cryoablation
using conventional CT scanners, Broomfield
hospital benefits from a state-of-the-art
interventional radiology theatre, which
is used for these image-guided ablation
procedures. The theatre includes the
Xperguide needle guidance system, which
allows extremely precise placement of the
needles within the tumour. Broomfield is the
first hospital in the UK to be performing renal
tumour cryoablation using this technology.
February 2013
Broomfield applied to become a designated
Level 2 Trauma Unit early in 2012, and
a large amount of work was required to
demonstrate that Broomfield had the
facilities, resources and organisation to
receive and care for trauma casualties.
Designated Trauma Unit status was
provisionally granted in July and fully ratified
in September 2012.
February 2013
The Maternity Unit at the Trust has
maintained its level 2 CNST status
Maternity Services at Broomfield Hospital
have retained their level 2 Clinical
Negligence Scheme for Trusts (CNST) status
following a successful assessment by the
NHS Litigation Authority (NHSLA) team.
The Trust now home to a Top Trauma Unit
The Trust continues to expand its growing
clinical reputation with the Trust being
awarded the status of a designated Level 2
Trauma Unit.
Trauma is the leading cause of death in the
under 40s, including children. To improve the
quality of care provided to seriously injured
patients, the Department of Health divided
the country up into separate regions.
It was designated that in each region there
would be a major trauma centre (Level 1
Trauma Unit) equipped with all specialities.
This includes neurosurgery, cardiothoracic
and plastic surgery. The other hospitals
within the region would receive accident
casualties (called a Level 2 Trauma Unit).
The NHSLA provides an ‘insurance scheme’
to NHS Trusts through the CNST, and Trusts
have to meet certain standards of care
that show they are providing safe and high
quality care to women and their families.
This is promoted by the effective use of risk
management strategies to minimise the risk
of harm to patients.
Because of the different nature of claims in
NHS maternity services a separate set of
CNST standards are in place. Each standard
covers an area of risk and has ten specific
underpinning criteria, against which all
Maternity Services are assessed.
As long as the hospital had the expertise and
the requirements stipulated by the region to
receive these injured patients they would be
awarded a Level 2 status.
Broomfield Hospital is part of the Eastern
region, and Addenbrooke’s Hospital in
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March 2013
First in the country for national
accreditation in theatres
Staff in the Trust’s theatres and anaesthetics,
have set a new precedent by being the first
NHS Trust theatre department in the country
to be awarded accreditation to ISO 9001.
The certification means that every element
and process of the patient pathway in
theatres is measureable against a quality
standard, which is nationally recognised.
With the new system in place, staff can
demonstrate to external auditors that
theatres are well maintained and compliant
with the required standard, equipment is safe
and compliant, and staff are fully trained to
use the equipment within their area.
The department will be audited on an annual
basis and in addition to the checks already
carried out by theatre staff, the ISO system
will also introduce internal process audits
which will provide additional confidence
regarding the compliance of the department.
This new system is in place to provide the
patients we care for with the highest quality
service from their theatre experience. Staff
will also directly benefit from the new system,
as they will each have a training pack
providing a portfolio of evidence that they are
qualified to work in their area.
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05 - Looking back to 2012/13: a summary of
our achievements
This section of the Quality Account provides an update on progress against last year’s priorities.
For each priority a summary is provided of the rationale for selection, current status, steps taken
to improve performance and any additional initiatives to be implemented in 2013/14.
Priority 1: improve the management of the deteriorating patient
Description of the issue and rationale for selection
It is recognised both nationally and locally that failure to consistently detect and act quickly
when a patient deteriorates is a significant cause of patient harm. This issue is referred to as
failure to rescue.
Measures to improve the recognition and management of patients include use of a Track and
Trigger system that alerts staff to significant change, ensuring staff are trained and competent
to undertake the observation and use the Track and Trigger system and ensuring there is an
appropriate response to any deterioration. Within the Trust this issue was recognised to be a
key priority for improvement during 2012/13 as a result of a number of reported incidents.
Key objectives to reduce harm
Working in partnership with our Commissioners, a CQUIN scheme was developed to drive
improvements for the period March 2012 to April 2013. This scheme included a number of
measurable targets to ensure:
• Assessment of the competence of all new and existing Healthcare Support Workers
(HCSW) to complete physiological observations and record of the Track and Trigger Score;
and
• Improvement in the recording of complete sets of patient observations, the accuracy of
Track and Trigger scores and documentation of escalation and the clinical response.
Current status
The Trust has achieved significant improvements in the management of the deteriorating
patient. The Trust met the targets of the associated CQUIN scheme:
Quarter 2
Quarter 3
Outcome
Training milestones
50% of new and existing HCSW
assessed as competent in the
recording of observations and
Track & Trigger scores
70% of new HCSW and 75%
existing assessed as competent in
the recording of observations and
Track & Trigger scores
Met
Observations milestones
50% completed set of
observations and appropriate
Track and Trigger score
70% completed set of
observations and appropriate
Track and Trigger score
Met
Escalation and action
50% of patients escalated, with
documented medical response
75% of patients escalated, with
documented medical response
Met
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29
In addition dedicated support from a Trigger
Response Team has been piloted from
November 2012 to March 2013. This team
provide support between 9 am and 5 pm
Monday to Friday attending and offering
advice and timely intervention in response
to requests from nursing staff. This scheme
has resulted in an immediate reduction in
the number of incidents relating to failure to
rescue.
patients will fall whilst in hospital, the Trust
has developed a framework to minimise the
risks to patients. This framework includes
a policy that describes the processes for
assessing adult patients on admission for
the risk of falls, training provision to ensure
staff are familiar with best practice, and
documentation to support risk assessment
and care planning.
Key objectives to reduce harm
Initiatives for 2013/14
Maintaining high levels of compliance with
the documentation of observations for our
patients and use of the Track and Trigger
system remains a priority for the Trust.
The Trigger Response Team pilot will be
continued in 2013/14 and it is anticipated
this will become a 24/7 service. The audit
programme will continue with the expectation
of maintaining compliance levels of 90% or
above. The Trust will follow national guidance
by adopting the National Early Warning
Score (NEWS) Track and Trigger system
in place of the local system. This will mean
that as staff move from one organisation to
another, they will recognise and be familiar
with this system. Any failure to rescue issues
will continue to be discussed at monthly
Patient At Risk Group meetings led by an
Intensive Care Consultant and attended by a
multidisciplinary team.
Priority 2: minimise the incidence of
patient falls and the severity of harm
caused
Description of the issue and rationale for
selection
Patient falls are recognised both nationally
and locally as a significant cause of patient
harm. Whilst it is inevitable that some
30
During 2012/13 the following objectives were
met:
• The introduction of an electronic
incident reporting system has supported
more accurate and improved reporting
for falls across the organisation.
• The falls risk assessment and
management tool were revised..
Current status
Patient falls remains one of the top 5
categories of reported incidents; however
the vast majority result in no harm or minor
harm. A number of work streams have
been developed or continued to ensure
high levels of awareness amongst staff
about the risk of patients falling. These
include the implementation of the electronic
reporting system which has resulted in
increased levels of reporting and awareness
amongst staff and will allow the identification
of common themes. Furthermore the
Trust participates in the national Safety
Thermometer initiative which includes
determining the incidence of falls amongst
patients in hospital on a given day each
month and monthly falls data is included
within the Patient Safety and Quality
dashboard to ensure patient falls remains
high on the governance agenda. In addition
the Trust hosted a successful region-wide
Falls Conference in May 2012
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Improved templates for risk assessment and
care planning were launched in January
2013, following multidisciplinary review of
the existing documentation, and an audit is
currently under way to establish the impact of
this initiative.
Formal training sessions have continued
throughout the year and an e-learning
package for falls management is available for
staff. Dementia patients are at an increased
risk of falling and dementia training has
been delivered through a number of forums
including bespoke training for Baddow and
Braxted wards.
Initiatives for 2013/14
Managing the risks associated with patient
falls remains a priority for the Trust. A
designated lead for falls will be identified to
work with a Falls Steering Group to drive
improvements. This will not necessarily result
in fewer falls being reported as increased
awareness amongst staff leads to high levels
of reporting. The Trust will, however aim to ,
reduce by a minimum of 10% the number of
patients suffering moderate or severe harm
as a result of falling in hospital.
Priority 3: reduce the incidence of
Hospital Acquired Pressure Ulcers
Description of the issue and rationale for
selection
A pressure ulcer is damage that occurs
tothe skin and underlying tissue when
constantpressure shuts down the blood
vesselssupplying that area. When
patients are illthey become more at risk
of developingpressure ulcers, particularly
if they aremalnourished, retaining fluid
underneaththe skin, bed bound or have
frail skin. Assuch the Trust must ensure
that all adultpatients are examined and
risk assessedon admission to see if there
is any existingdamage or the potential for
pressure ulcersto develop. The majority of
pressure ulcersare avoidable if the correct
interventions arein place and as such
reducing the incidenceof pressure damage is
a priority for the Trust.
Key objectives to reduce harm
During 2012-13, the Trust adopted a zero
toleranceapproach to the incidence of
avoidablehospital acquired Grade 2, 3 and
4 pressureulcers and the following initiatives
implemented:
• Implementation of Atmosair selfadjusting pressure redistributing
mattresses,
• Develop access to new documentation
templates via the Intranet,
• Provision of additional guidance and
training for staff,
• Review of resources within the Tissue
Viability Team,
• Establishment of a Pressure Ulcer
Panel to review all untoward Pressure
Ulcer incidents.
Current status
During 2012/13 the Trust, like other
Truststhroughout the UK,did not achieve
thenational target of achieving zero grade 2
to 4 acquired pressure ulcers. Indeed there
was an increase in the levelof reporting of
both inherited and hospitalacquired pressure
damage. This is thoughtto reflect increased
awareness amongst staffand the introduction
of an electronic incidentreporting system in
April 2012.
During 2012/13, the Pressure Ulcer panel
was established, Tissue Viability Team
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31
resources reviewed and additional resources
made available on the Trust intranet and
training programmes put in place. Teething
problems relating to the implementation
of new Atmosair self-adjusting pressure
distributing mattresses are still being
addressed.
Key objectives to reduce harm
Key to minimising the risk of infection is
achieving high levels of compliance with
hand hygiene and bare below the elbows
standards.
Current status
Initiatives for 2013/14
• Maintain a zero incidence of Grade 2 to
Grade 4 avoidable pressure ulcers,
• Appoint a second Tissue Viability
Clinical Nurse Specialist in June 2013,
• Maintain and develop the educational
and training provision for staffincluding
the use of the Atmosair mattress
• Phased implementation of pressure
relieving cushions for all patients
throughout the MEHT,
• Launch the revised wound care
formulary that includes high quality
wound dressings,
• Develop links and MDT care pathways
with the community for the prevention
and management of both pressure
ulcers and leg ulcers.
Priority 4: reduce the incidence of
Catheter Acquired Infection
Description of the issue and rationale for
selection
Some patients require a urinary catheter
whilst in hospital and this will make the
person more vulnerable to urinary tract
infection. It is therefore vital that strict
hygiene is employed during the care of these
devices and that the catheter is removed as
soon as possible.
32
The number of in-patients with urethral
catheters is reported on one day of
each month as part of the patient safety
thermometer data collection. There is
scrupulous attention paid to the insertion
and management of invasive devices. There
is ongoing documentation and audit of High
Impact Intervention for urethral and suprapubic devices and this information feeds into
an infection control scorecard included in the
Director of Infection Prevention and Control
(DIPC) report each month. This is reported at
Directorate Governance meetings.
Initiatives for 2013/14
Minimising all hospital acquired infections is
a key priority for the Trust in 2013/14.
Fundamental to the infection prevention
programme will be working towards 100%
compliance with hand hygiene.
The infection prevention team will review the
safety thermometer urinary catheter data on
a monthly basis.
Priority 5: improve the prevention
and management of Venous
Thromboembolism (VTE)
Description of the issue and rationale for
selection
VTE, or the development of a blood clot, as a
result of a hospital admission is a significant
cause of avoidable patient harm with the
potential to lead to long-term disability or in
some cases, death. Preventing avoidable
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VTE has been recognised as a clinical
priority for the NHS by the National Quality
Board, the NHS Leadership Team and locally
by MEHT and partner organisations.
Key objectives to reduce harm
To minimise the associated risks the Trust
has measures in place to ensure all patients
are assessed for their risk of developing
blood clots and where risks are identified,
patients receive appropriate medication.
In recognition that the documentation of VTE
risk assessment and related prescriptions
could be improved, a multidisciplinary team
reviewed the structure of the drug chart. A
revised version was launched in March 2013
and it is anticipated this will help to maintain
and improve standards of care for our
patients. This revised template also brings
together a number of other assessments
targeted to improve medicines management.
Initiatives for 2013/14
Specific CQUIN scheme targets for the
Trust, were in place during 2012/13 relating
to the number of patients admitted that were
assessed for their risk of developing VTE
and the number of adult inpatient admissions
receiving appropriate prophylaxis as
indicated by VTE risk assessment.
Minimising the risks of VTE for our
patients will remain a priority in 2013/14. A
programme of regular audit will continue and
the Thrombosis group lead by a specialist in
this area of medicine will continue to drive
improvements.
Current status
During 2012/13, MEHT consistently achieved
compliance levels of over 95% for VTE risk
assessment (refer to the National targets
and benchmark indicators section below).
In addition, the Trust met the requirements
for provision of medication to reduce the
likelihood of blood clots developing.
Quarter 1
Quarter 2
Quarter 3
Outcome
VTE risk assessment
95% (or above) of all adult inpatients each month must have
had a VTE risk assessment on admission to hospital using the
clinical criteria of the national tool
Met
VTE prophylaxis
90% or above of all adult inpatients
indicated as requiring prophylaxis
from a VTE risk assessment to have
received as appropriate
Met
95% (or above)
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33
06 - Review of Quality Performance
The Midlands and East Strategic Health Authority have introduced a performance benchmarking
report. This report uses the selected indicators that the SHA uses to benchmark itself against
the rest of the NHS in England. This information replaces some of the previous benchmarking
information provided by the SHA.
Monthly position out of total East of England Trusts
The benchmarking report evidences Mid Essex Hospitals transformation in quality and service
performance. For the 13 publications to date, the Trust has remained in the top 10 performers
list.
December 2012 bulletin 38
34
Performance measure
Rank
Patient experience
A&E - % within 4 hours (incl. Walk in Centre)
MRSA rates
C diff rates
Mixed Sex Accommodation breaches
RTT overall rank
Cancer waiting times
24th
10th
1st
14th
1st
12th
8th
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median
upper quartile
upper quartile
median
upper quartile
upper quartile
upper quartile
Other quality indicators
National targets and benchmark indicators
Summary Hospital-Level Mortality Indicator (SHMI):
Description of the issue and rationale for selection
Understanding and analysing hospital mortality, using one method, when used with other
important quality metrics, to help understand the quality & Safety of care a Trust provides.
During 2011/12 in line with national recommendations, the Trust adopted the Summary Hospitallevel Mortality Indicator (SHMI), which is reviewed alongside Hospital Standardised Mortality
Ratio (HSMR) and other contextual indicators, such as the Global Trigger Tool (a measure of
the rate and type of harm present in an organisation). These measures enable us to compare
the number of deaths occurring in our hospital with the rate statistically expected taking into
account factors such as the patient’s age, their main illness, other medical conditions and where
they live.
SHMI greater than 100 means that more deaths occurred than statistically expected, and SHMI
of less than 100 means that fewer deaths occurred than expected. This does not necessarily
mean that the care was poor (or good), or that lives were lost (or saved). SHMI values must
always be interpreted relative to calculated ‘control limits.’ These are upper and lower limits
within which mortality is expected. It is entirely normal for SHMI to fluctuate around (above or
below) 100 and a figure anywhere between the upper and lower control limits is considered to
be acceptable. However, any sustained upward trend is viewed as a cause for investigation, just
as SHMI outside the control limits (an ‘outlier’) would be. This has often been conceptualised
as a “smoke alarm” – a rising or high SHMI may not always indicate harm, but is always an
indication for investigation.
Source NHS IC
SHMI (source: NHS IC) July 2011 – June 2012 (Rolling 1 year period, 6 months in arrears):
110 (Lower 89, Upper 113)
• Percentage of admitted patients whose treatment included palliative care; and 1.33%
(source: NHS IC) July 2011 – June 2012 (Rolling 1 year period, 6months in arrears
• Percentage of admitted patients whose deaths were included in the SHMI and whose
treatment included palliative care (Context indicator) 24.7% (source: NHS IC) July 2011
– June 2012 (Rolling 1 year period, 6months in arrears)
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35
This graph shows how our hospital mortality has changed over time in relation to the national
average of 100. This provides the hospital with an indicator of whether our mortality rates are
above average or following an upward trend, either of which trigger further investigation.
Source : HSMR = Hospital Standardised Mortality Ratio, SHMI = Summery Hospital level
Mortality Indicator, LCL = Lower Control Limit, UCL = Upper Control Limit. Chart data from Dr
Foster Intelligence as provided to NHS Midlands & East Quality Observatory (MEQO).
Key objectives to reduce harm
To consistently achieve SHMI below the expected rate.
Current status
The trending data for SHMI and HSMR have remained within control limits since Q1 2010/11.
This reflects the continued emphasis on patient safety at MEHT. Over the same period, SHMI as
reported by CHKS has increased, but remains within the control limits of this methodology.
The SHMI has been around 10 points higher than the HSMR for the past three quarters. It
is important to understand the key differences between HSMR and SHMI which are likely to
account for some of this difference. In contrast to the HSMR, SHMI includes deaths with a
Palliative Care code and deaths occurring up to 30 days following discharge from hospital.
36
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The observed difference is therefore
what might be expected in the setting
of decreasing in-hospital mortality rate
associated with a higher proportion of
patients dying outside of hospital, especially
as rates of palliative care coding increase.
the current SHMI reflects in-hospital factors
such as patient care, out-of-hospital factors,
or statistical factors such as coding.
Although it is debateable whether the last two
data points (109, 110) represent a genuine
upward trend or expected normal statistical
variation, the Trust is concerned by any
apparent upward trend, even within control
limits and continue to actively investigate any
such trend through detailed analysis by the
Trust’s Mortality Review Group (MRG).
In November 2012, Dr Foster Intelligence
notified the Trust that the Dr Foster
Hospital Guide will be adopting a different
methodology for calculating control limits. An
effect of this change is that MEHT will enter
the higher than expected banding for SHMI
for that methodology. At the time of writing,
SHMI as published by Dr Foster is 108.68,
with an upper control limit of 108.02 (using
99.8% control limits), which differs from one
of the bandings by the NHS Information
Centre. The NHS IC define control limits
using an over-dispersion banding, within
which this SHMI would be within expected
limits, but as the Hospital Guide will be using
99.8% control limits without over-dispersion,
SHMI for MEHT will appear in the Hospital
Guide as ‘higher than expected’.
Although other bandings in use and the
HSMR remain within control limits, MEHT
takes this seriously and it is necessary
to establish whether there has been
any genuine increase in crude mortality
underlying the published SHMI. In addition to
the ongoing monitoring detailed above, the
MRG is currently undertaking an additional
review of current data to establish whether
The Mortality Review Group (MRG), a
subgroup of the Patient Safety Group, was
established in September 2011 to support
the Trust Board in assuring that mortality is
proactively monitored, reviewed, reported
and where necessary investigated and where
appropriate lessons learned and actions
implemented to improve outcomes.
Through the MRG, the Board is assured that
MEHT has a well established programme of
proactive mortality review.
This is achieved by:
• Regular review of mortality data from
CHKS, QIE, MEQO and the NHS IC.
• Drill down and detailed reporting into
any areas of concern triggered by
outliers or upward trends.
• Systematic review of clinical specialties
/ diagnostic categories according to a
risk-based work plan.
• Review of all Serious Incidents leading
to mortality.
• Close working with the Medical
Examiner team as regular members of
MRG.
• Escalation of risks and learning
points to the Patient Safety Group
and relevant Directorate Governance
Meetings, with monitoring of action
plans, when required, by the Patient
Safety Group.
MEHT is committed to using mortality
indicators as part of our effort to improve
patient safety and quality of care. SHMI is
regarded as an effective measure of safety
and quality across the whole organisation,
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37
as the cumulative effects of many aspects of
care will influence the overall mortality rate
seen in the Trust.
Initiatives for 2013/14
The past two years have seen significant
changes to the MEHT corporate and
clinical governance structure reflecting a
consistent focus on ensuring patient safety
is our number one priority. This has lead to
significant improvements across a range of
objective measures of safety and quality.
For further details refer to section five.
Steps we have taken to improve during
2012/13:
• Continuation and development of all
initiatives commenced in 2011/12
• Delivery of multi-professional ward
based staff patient safety training
• Launch of Trigger Response Team pilot,
to improve detection and management
of patients at risk
• Introduction of ‘SBAR’ tool for improved
handover communication
• Increased incident reporting rates
following introduction of DatixWeb
reporting tool, leading to greater
learning
• Continued focus on patient safety
initiatives described earlier in these
accounts with positive feedback from
the Global Trigger Tool, driving further
reduction in SHMI
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• Transformation of Trigger Response
Team from pilot status to ongoing
service with extended hours
• Continued programme of multiprofessional ward based patient safety
training for all clinical staff
• Implementation of Board Rounds for
improved communication and patient
flow
• Focus on developing clinical leadership
as a driver for improved care
Patient reported outcome scores (PROMS):
Patient reported outcome scores for:
•
•
•
•
groin hernia surgery,
varicose vein surgery,
hip replacement surgery, and
knee replacement surgery
PROMs pre-operative questionnaire participation rates by provider
the number of valid pre-operative questionnaires as a proportion of the number of episodes
All
Yearly Performance Rates
10/11
71%
11/12
72%
Groin
10/11
29%
11/12
37%
Hip
10/11
89%
Knee
11/12
93%
10/11
92%
11/12
83%
Varicose Vein
10/11
57%
11/12
48%
Patient reported outcome scores or PROMS are key national patient experience questionnaires
which MEHT fully participates in. Patients are questioned both before and after their procedure.
The pre-operative questionnaire is supplied and collected by MEHT and the MEHT participation
rates published by the National PROMS team are shown below. The Trust response rates for all
procedures of 95-96% are in line with the national average.
Whilst the 10-11 response rates for groin hernia procedures were lower than the national
average, the provisional 11-12 data shows an improvement back in line with the national
average.
Emergency readmissions to hospital within 28 days of discharge
The Trust has identified lead clinicians to take forward improvement schemes to further
improve the readmission levels for the hospital. Through work with an external benchmarking
organisation the lead clinicians have identified specific areas to target improvements. In
addition to this work the Trust has Introduced an ambulatory care model for emergency
admissions which is intended to reduce unnecessary admission and ensure patients have the
support in place to safely return home. Please refer to tables on next page which indicate MEHT
performance against national data.
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Emergency Readmissions within 28 days for patients - Local data
Emergency Readmissions within 28 days for patients - National data
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Stakeholder Feedback
Patient Experience
For the period 2011/12, the Trust performance for responsiveness to the personal needs of
patients as measured by the National Inpatient Survey was 66.9% against a national average of
67.4%.
Friends and Family Test
The Friends and Family Test gives patients a platform to give feedback upon discharge that
the Trust can use it to identify areas that need to be improved or areas of good practice. It is
important that patient feedback is analyzed, compared from trust to trust and acted upon so
that any concerns can be identified and addressed. The Trust has consistently achieved a high
score which has remained in the top quartile of trusts across the region for 2012/13.
Responsiveness to inpatients’ personal needs: ensuring patients have a positive experience of
care
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Net
Promoter
59%
57%
59%
68%
80%
83%
76%
80%
85%
83%
74%
Score
Staff Experience
The table below indicates the proportion of staff who would be prepared to recommend the
Trust to friends and family compared to the national average. This data relates to 2011. It is
anticipated this figure will improve significantly in future years as a result of the Trust’s improving
record on quality and safety.
Percentage of staff who would recommend the provider to friends or family
needing care
MEHT
All Trusts
55%
60%
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41
Percentage of admitted patients risk-assessed for Venous Thromboembolism
The development of Venous Thromboembolim (blood clots) as a result of immobility and / or
surgery is a recognised risk to patients. As such it is important that the Trust risk assesses
patient admitted to the hospital. During 2012/13, MEHT consistently achieved compliance levels
of over 95%.
Venous Thromboembolism
National
(VTE) %
MEHT
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13
93.4% 93.6% 93.3% 93.9% 93.9% 94.0% 94.3% 94.4% 93.8%
n/a
n/a
n/a
96.3% 96.0% 95.4% 96.6% 97.2% 96.3% 96.8% 96.8% 96.4% 96.4% 97.1% 97.2%
Healthcare Acquired Infection
The Trust has in place a robust framework to minimise the risks of healthcare acquired infection
to patients. This includes dedicated staff to implement the infection prevention and control
strategy, training and support for all staff protocols and documentation to support good practice
and a robust audit programme to monitor practice. In addition challenging targets are imposed
by the Department of Health to help drive continual improvement. For 2012/13, the Trust did not
exceed the mandatory standard of 1 MRSA bacteraemia case and 22 Clostridium difficile cases.
Reduction in the number of patients developing Clostridium difficile diarrhoea is a national
priority and continues to be a key priority for MEHT. It causes distress to patients, is costly
and prolongs hospital stay. MEHT has consistently reduced the number of patients developing
diarrhoea associated with Clostridium difficile over the past four years and has achieved
numbers much lower than the annual ceiling set.
2012/13
Apr-Mar
The actual number of cases of C diff in respect of all NHS patients age 2 or above
treated by MEHT in 2012/13
The inpatient bed days in respect of all NHS patients for the provider in 2012/13
(KH03 return)
17
175,740
9.67 per 100,000 bed days
Our outturn for hospital attributed cases in 2012/13 is 17 against a ceiling of 22 set by the
Department of Health. The Trust had a rate of 9.67 cases of Clostridium difficile per 100,000
bed days for the period 2012/13. In the previous year the Trust reported a rate of 11 against
national performance of 22.
In 2013/2014 the target will be no cases of MRSA bacteraemia and a maximum of 12 cases
of Clostridium difficile. Infection prevention and control remains a key priority for the Trust and
as such meeting these challenging ceilings of compliance and maintaining good hand hygiene
practice has been identified as a priority for 2013/14. Monthly surveillance will be reported by
the Director of Infection Prevention and Control to the Patient Safety Group, Patient Safety and
Quality Committee, MEHT Trust Board and the Clinical Commissioning Group.
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Patient Safety Incidents
It is recognised that in large organisations delivering complex healthcare to large numbers
of service users, things will on occasion go wrong. It is therefore essential that MEHT has
a process in place that allows these incidents to be reported and investigated so that local
and organisation learning can occur. In addition anonymised clinical incident data is regularly
submitted to the National Reporting and Learning System to allow thematic analysis.
Historically MEHT had a culture of low reporting which indicates that the opportunities for
improvement as a result of incidents were limited.
In response an electronic reporting system was purchased in 2011 to provide staff with easy
access and to reduce the administrative burden. Since the scheme was fully implemented in
April 2012, the level of reporting has increased significantly and the most recent report, the
NRLS report commissioned by the NHS Commissioning Board but published by Imperial
College Hospital evidences the Trust’s continued upward trajectory on patient safety incidence
reporting.
Trust staff reported 7566 clinical and non-clinical incidents during 2012/13, a significant increase
from last year. Of these 6329 related to patient safety incident and 1237 to staff or facilities
incidents. Of the patient safety incidents reported 95% resulted in no harm or minor harm.
Rate of patient safety incidents*
Percentage resulting in severe harm or death
Source: Local data. National data from
previous years is incomplete
3321 per 100,000 bed days
1.06%
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43
Improving the Patient Experience – Listening to our patients
Friends and Family Survey
The Friends and Family survey was implemented in all inpatient wards in April 2012. This
survey asked all patients on discharge if they would recommend the ward to their friends or
family should they need it. Patients were also asked to tell us what the top three factors were
that influenced their feedback and to share any additional comments they would like to give.
By the end of 2012 over 80% of our patients said they would recommend our wards to their
friends or family should they need them. The Trust has consistently been rated by our patients
as one of the best hospitals across the Midlands and East.
The top three factors determined by our patients, which influenced their feedback, were:
Ranking
1
2
3
Important Factors in the Wards
Being treated with dignity and respect
Cleanliness of the ward
Felt listened to by staff
Real examples of Patient Feedback given in 2012
1
Type of Ward
You cannot get better treatment anywhere, it is
first class.
Medical Ward
2
I have been very impressed with the high level of
care from all staff. A wonderful team. Many thanks Surgical Ward
to all concerned.
3
We felt very re assured after a very worrying
experience with our young son, the staff
and surroundings were excellent
Children’s Ward
4
All the staff have been friendly, approachable,
professional and non-judgemental. I work for
another NHS Hospital, I am so impressed by your
superb treatment, and I am so pleased we were
brought here. I cannot fault it. A special mention
for how clean the ward is and how friendly the
cleaners are.
Burns Ward
5
Fantastic staff, the nurses are amazing, brilliant
surgeons; everyone is kind, courteous and
friendly. I thank you all
Surgical ward
6
44
Patient Feedback
Very impressed by the kindness and care shown
by all staff
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Medical Ward
Improving Responses to Complaints
MEHT is committed to providing accessible, fair and effective support and processes for those
who wish to express their concerns with regard to the care, treatment or service provided by
the Trust. The Trust aims to respond to complaints within 25 working days 85% of the time.
The cumulative figure for the year, as at the end of January 2013, was 76%. Whilst this is an
improvement on the previous year’s performance, actions to further improve responses to the
complaints process have been developed and implemented during 2012/13. These include:
• New policy development to build a culture and processes that put the patient first in
addressing complaints
• Strengthened and increased the leadership and direction of the complaints team
• Strengthened the skill base and increased the number of complaints coordinators to
provide additional support to the Directorates
• Restructured the complaints department to ensure one coordinator is dedicated to each
Directorate
• Weekly Directorate meetings take place between the coordinators and the respective
Heads of Nursing and lead nurses to track complaints
• The Patient Advice and Liaison Service now aim to resolve issues to prevent unnecessary
delegation to clinical staff
• The Trust proactively monitors and responds to all comments posted on Patient Opinion
and NHS Choices.
• The team actively support clinical staff to resolve department issues as they occur
• The complaints managers’ triage all complaints received each day this enables a proactive
response and where required rapid escalation
• Early contact with a complainant is made in the event of a complex complaint so that an
opportunity is given to talk to or meet clinical staff
• Robust support provided for complaint meetings held with CEO or Executives
• Developed a monthly report for the Executive which enables the monitoring of
performance
• In the light of a recent audit of responses a revised complaints policy will be launched
in March 2013 this will now take into consideration the recommendations of the Francis
report
During 2013/14, achieving 85% of complaints responded to within 25 days will be a priority for
the Trust. A monthly progress report will be provided for the Trust Executive Committee and
Senior Clinical Team with a bi-monthly report to the Trust Board. Work will focus on timely, clear
and concise complaint management with the patient at its core. Feedback from the Complaint
Ombundsman notes significant improvement in complaints since 2011.
Managing compliments
The Trust acknowledges all compliments it recieves via the Patient Advice and Liaison
Service (PALS) and Complaints Department. Once received these are shared with the staff
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or department concerned. Thanks and
recognition of positive patient feedback/
experiences is given to the staff concerned.
The Trust proactively monitors all comments
posted on NHS Choices and Patient Opinion.
Positive comments are acknowledged and
the sender is thanked for taking the time to
send them to us, again these are shared with
the relevant staff. Free text comments that
are provided via the Trust surveys in wards
and the A&E department are circulated to
ward sisters and heads of department on a
weekly basis to ensure they are shared with
the staff concerned.
The Mid Essex Mealtime Mission
Background
We have all read the headlines about busy
hospital settings that deliver outstanding
clinical care but lose sight of ensuring
complete patient care, consistent delivery of
nutrition and hydration, dignity and respect
and good communication. The Mid Essex
Mealtime Mission is a new innovative
approach to ensure we have a reputation
for being a hospital who takes care of the
things that matter most to patients and do
not lose sight of the simple but extremely
important aspects of care. The Mid Essex
Mealtime Mission is a patient focused
initiative that aims to ensure we become a
Trust that provides the maximum support for
our patients to receive the optimum level of
nutrition and hydration.
We have recruited volunteer mealtime
companions to enhance the patient
experience. These Mealtime companions
help to prepare the wards for mealtimes.
The mealtime companions’ primary role is
to encourage and provide companionship
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at mealtimes, assist patients who require
support when eating their meals providing
regular encouragement and reminders to
drink plenty. The companions champion
dignity in care and offer time to talk to
patients and their relatives. These valuable
interactions are known to enhance the
patient experience and provide support to the
busy nursing team.
We have built upon our existing partnership
with Chelmsford College, which historically
provided some work experience placements
for students that are studying Health
and Social Care, a course designed for
people that are looking to gain a career in
healthcare. This innovative approach to work
placements offers students a structured and
valuable experience of an acute healthcare
setting.
Overall Aim
To improve the experience for Mid Essex
Hospital Trust patients, and in doing this,
support students who will benefit from direct
clinical experience which enables them to
gain an insight into a future healthcare
career.
Providing the correct nutrition and hydration
is a fundamental part of care. We aim to
provide an excellent patient experience,
promoting healing and recovery, whilst
reducing the risk of complications during a
stay in hospital.
Strategy
This exciting initiative grew from the need to
provide support to our patients who require
help with nutrition and hydration throughout
the day, while also providing an enriching
and valuable life experience for our local
young people who expressed an interest in
pursuing a career in healthcare.
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Objectives of the initiative
We offered placements to 60 work experience students as part of their course in Health and
Social Care.
The Professional Development Nurse and Mealtime Mission Project Lead, provided a
multidisciplinary training session for the students which raised their awareness of the
importance of nutrition and hydration, dignity and respect, communication and supporting
patients with their nutritional requirements. The students were given the opportunity to try
patient food and practice supporting each other with eating and drinking.
We now provide regular support to the students and hold catch-up sessions with the volunteer
manager and the professional development nurse.
We liaise with Chelmsford College regarding the progress of students on the placement.
Results so far
This new initiative has so far offered 61 students from Chelmsford College the opportunity for
a work placement that will also help us to enhance the patients experience during their stay
by providing additional time to communicate, provide companionship and promote improved
nutrition and hydration.
The students are supporting the clinical team to provide patient centred care. This additional
help enables nurses to focus their time with patients.
Real time Inpatient Survey
In 2012, a new real time inpatient survey was implemented. This survey asks all patients
anonymously via their bedside TV what they think about the care they have received. To date
over 5,000 patients have provided invaluable feedback, which has helped us to make positive
changes and therefore improve the care we provide. This survey covers five key areas of
feedback, which are monitored nationally.
These are:
1. Were you involved in decision made about you?
2. Did you have someone to talk to if you were worried about anything?
3. Were you given privacy when discussing your condition or treatment?
4. Were you told about the side effects of your medication to watch out for when you
went home?
5. Were you told who to contact when you got home if you were worried about your
condition or treatment?
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In the last year due to the work undertaken
by the Patients Experience Team and the
Patients Council the feedback from our
patients for each of these areas has shown a
marked improvement. For example, patients
have told us they are more satisfied with the
information they are given about who to ring
if they are worried after they go home.
Trust’s website and it will be shared at public
Trust Board Meetings.
A new discharge card was implemented from
August 2012, which gives them the details
of the ward they have been discharged
home from. It also provides the name and
contact details of the Ward Sister and the
Lead Nurse should the patient need to talk to
someone when they get home.
Feedback from this survey told us patients
were finding the wards noisy at night.
As a direct result of this, the Trust launched a
“Ssh campaign”, which reminded all our staff
of the importance of minimising noise at night
so that our patients can get a good night’s
sleep.
Survey Developments in 2013
From April 2012, as instructed by the
Department of Health, the Friends and
Family survey will be implemented in our
Accident and Emergency Department. All
adults who are discharged home will be
asked via a kiosk or postcard whether they
would recommend our A&E department to
friends or family should they need similar
care. A specific Friends and Family survey
for Maternity patients will be implemented in
October 2013.
Publication of Patient Feedback
From May 2013 the public will be able to
access the feedback we have received from
the Friends and Family Test survey via the
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07 - Looking forward to 2013/14: priorities for
improvement
Looking forward to 2013/14: priorities
for improvement
• To work towards 100% compliance
with hand hygiene as a fundamental
standard of safe patient care
The 2013/14 priorities for improvement
were developed through review of a range
of quality indicators and build upon those
from 2012/13. These priorities are informed
by the commissioning process and the
CQUIN scheme and each is associated with
measurable objectives.
Priority 3: to improve clinical outcomes and
effectiveness led by the Associate Medical
Director with responsibility for Patient Safety
Priority 1: to improve patient safety led by the
Associate Medical Director with responsibility
for Patient Safety
• To achieve a minimum of 95% of all
adult inpatients assessed for their risk
of Venous Thrombo-Embolism (VTE)
and prophylaxis prescribed if patient
are at risk
• To reduce by a minimum of 10% the
number of patients suffering moderate
or severe harm as a result of falling in
hospital
• To maintain a zero tolerance approach
to avoidable, hospital acquired grade 2,
3 and 4 pressure ulcers
Priority 2: to reduce hospital acquired
infections in line with national and local
targets led by the Director for Infection
Prevention and Control
• To maintain zero-tolerance approach
to hospital associated Meticillin-related
Staphylococcus aureus (MRSA)
infection
• To consistently achieve a Summary
Hospital Level Mortality Indicator
(SHMI) at or below the expected rate
through:
a. Continued programme of multiprofessional ward–based patient
safety training for all clinical staff
b. Implementation of Board
Rounds for improved communication
and patient flow
c. Focus on clinical leadership as
a driver for improves care
• To improve the early identification and
management of the deteriorating patient
through:
a. Continue regular audit of
patient observations and maintain
90% achievement of complete sets
of observations with appropriate
escalation and medical response
b. Implement National Early
Warning Tool (NEWS)
c. Transformation of the Trigger
Response Team from pilot status to
on-going service with extended hours
• To reduce hospital associated
Clostridium difficile below imposed
ceiling of 12 cases
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Priority 4: to continuously improve the
experience of service users and their
families and / or carers led by the Director of
Communications and Chief Nurse
• To maintain the Friends and Family
test score and improve the National
Inpatient Survey by a further 4 points
• To ensure 85% of complaints are
responded to within 25 days
• To improve the care of patients with
Dementia through:
a. achieving 90% compliance with
dementia diagnostic assessment of
relevant patients
b. enhancing the ward
environment for patients
c. increasing patient and carer
satisfaction with the Butterfly scheme
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08 - The Way Forward
The Trust’s quality and service performance
has significantly improved during 2012/13 to
the point that the Trust is the best performing
Trust in the East of England and Midlands
Strategic Health Authority Region. That said
we are focused to maintain the quality of
our services and continue to learn based on
feedback from our patients, visitors, staff,
commissioners and the CQC. The Trust
remains committed to deliver our strategy to
“Care, Excel, Innovate.”
• To promote the sustainability agenda
across the Trust for all staff and
services to embrace
• To work with the Carbon and Energy
Fund on a new carbon energy centre
• To enhance the ward environment for
persons with dementia
• To deliver mobile wireless access in
the new trust wing for improved patient,
visitor and staff communications
• Improve internal and external
communications to build a positive
reputation.
Specific key performance areas the Trust
wishes to improve further include:
• Accurately assessing all patients needs
and ensuring we meet their individual
need and support requirements
• Patient health records to be certain that
all information is recorded accurately
and is up to date at all times
• Medications management to ensure
we have robust processes in place
including storage, security and
information for patients on medications
• Eliminate all hospital acquired,
avoidable pressure ulcers and skin
damage
• Reduction in the number of patients
waiting over 18 weeks
• Further improvement against the range
of recognised stroke indicators.
• Delivery of all A&E clinical outcome
indicators
• To continue to develop a responsive,
patient centred complaints
management culture at the Trust
• To continue to improve the timeliness
and quality of electronic discharge
letters issued to GPs
• To further reduce the number of
unnecessary outpatient follow up
attendances
• To reduce the number of cancelled
operations on the day of admission
Capital and investment strategy
The Trust’s focus in 2013/14 is to apply
capital resources in ways that secure
significant, recurrent revenue savings whilst
maintaining the safety and quality of the
service.
Priorities for investment include:
• Continued estates rationalisation, to
build upon the significant work delivered
in 2012/13, to eliminate legacy costs
from the residual estate and improve
clinical efficiencies through better
service and support adjacencies
• ICT investment to integrate existing
clinical systems and remove paper
based clinical and support systems
• Improved patient and visitor information
on our services with an enhanced,
accessible online web site
• Replace medical equipment
• Establish dedicated day surgery
facilities
• Backlog maintenance on the non-PFI
parts of the site that remain
• Better patient facilities including car
parking.
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The Trust has been through an extensive
process of staff, public, partner and patient
engagement and involvement in developing
an organisational strategy that maps out
key quality goals in relation to clinical
effectiveness, patient safety and patient
experience.
the journey and marks the beginning of a
modern health delivery organisation working
in partnership with the community. The Trust
has further work to do to create a dynamic
flexible organisation with a culture that
supports innovation and excellence.
Improvement will also be driven through
the development, in partnership with the
CCG of an appropriate and challenging
Commissioning for Quality and Innovation
framework that reflect these quality goals.
Workforce
The development of local quality goals
allows the Trust to focus on specific areas
of concern. The quality goals identified for
2013-14 are described in section 7 above.
These quality goals, which are specific and
measurable, will be driven by an effective
performance monitoring process that ensures
awareness and accountability from Board to
Ward. This includes a programme of audit
and monitoring to assess performance;
reporting of performance indicators within
the Safety and Quality dashboard and is
reviewed by the Patient Safety & Quality
Committee.
The Trust has worked closely with it’s
commissioners to ensure that contracts for
2013/14 reflect the national priorities as set
out in the national operating framework.
The Trust will maintain our focus on quality
for the patients we serve and will work with
the National Trust Development Authority
to determine our aspiration to become a
Foundation Trust as this will support the
Trust to operate effectively within a dynamic
and competitive market.
The Trust recognises that achieving
Foundation Trust status is not the end of
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The Trust is operating in a period of
unprecedented change across the NHS with
many new organisations and requirements
for our teams. In recognition of these
changes and the impact they have on the
Trust’s workforce, the Trust is continuing
to review its workforce strategy. This is
being led by the new Director of Human
Resources, Bernard Scully who joined the
Trust in January 2013.
During 2012 we undertook an extensive staff
survey, named Staff Impressions and gained
excellent insight from our staff about what
is important to them. The overwhelming
majority felt MEHT was a good place to
work and would recommend our services
to a friend or family member. However,
our staff did tell us that we need to treat
them as individuals, improve our internal
communications and improve our learning
and development programmes and we are
committed to work on these areas during
2013/14.
The overarching aim is to deliver a
comprehensive workforce strategy to
create a workforce that has the capacity
and capability to deliver patient care
effectively and efficiently in a changing health
landscape.
Some of the initiatives planned for 2013/14
that will be developed as part of the strategy
will include:
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• Workforce strategies to ensure
the Trust recruits and retains high
calibre employees and creates an
infrastructure to support their well-being
in the workplace.
• Review of the Trust’s Organisational
Development (OD) strategy – this will
incorporate the implementation of a
leadership development framework that
will facilitate improved leadership skills
that reflect the values and behaviours
of the Trust
• Employee and Board Development
programmes to improve the capabilities
of all those involved in delivering
services and governing the Trust.
2013 and will actively look to recruit a new
Chief Executive to join a now stable, capable
Board that benefitted from an extensive
leadership and corporate development
programme in 2011/12.
Through these initiatives the Trust is
confident that it has the leadership and
workforce to ensure the Trust is a healthcare
organisation that puts patients first and
whose reputation for excellence and
innovation inspires our patients, staff and the
population we serve.
Board development
The Board and executive team is committed
to building on the success of 2012/13 in
terms of improving the quality of patient
services. In addition, as a Board we are
listening to the feedback from our staff and
have made a commitment to all our staff
to make sure we are visible and actively
involved across the Trust. We have a regular
schedule of planned and unannounced visits
for all our Board and a series of staff events
to ensure all remain updated during this
period of significant change in the NHS.
This year we will be sorry to see our Chief
Executive, Malcolm Stamp CBE leave the
Trust as he takes on an exciting new role
in Brisbane, Australia from the summer of
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09 - Auditors Limited Assurance Report
INDEPENDENT AUDITOR’S LIMITED
ASSURANCE REPORT TO THE
DIRECTORS OF MID ESSEX
HOSPITAL SERVICES NHS TRUST ON
THE ANNUAL QUALITY ACCOUNT
We are required by the Audit Commission
to perform an independent assurance
engagement in respect of Mid Essex Hospital
Services 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”).
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.
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
• Percentage of patients readmitted
within 28 days.
We refer to these two indicators collectively
as “the indicators”.
Respective responsibilities of Directors and
auditors
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 Directors are required under the Health
Act 2009 to prepare a Quality Account for
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• 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.
• the Head of Internal Audit’s annual
opinion over the trust’s control
environment dated 25 May 2013;
• the annual governance statement dated
6 June 2013;
• Care Quality Commission quality and
risk profiles dated May 2013; and
• the results of the Payment by Results
(PbR) coding review dated April 2013.
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 June 2013;
• papers relating to the Quality Account
reported to the Board over the period
April 2012 to June 2013;
• feedback from the Commissioners
dated 25 May 2013;
• feedback from Local Healthwatch dated
17 May 2013;
• the trust’s complaints report published
under regulation 18 of the Local
Authority, Social Services and NHS
Complaints (England) Regulations
2009, included in the Annual Report
published June 2013;
• feedback from other named
stakeholder(s) involved in the sign off of
the Quality Account;
• the latest national patient survey dated
February 2012 for outpatients and April
2013 for inpatients;
• the latest national staff survey dated
2012;
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 Mid Essex
Hospital Services 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 Mid Essex Hospital Services
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
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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.
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 nonmandated indicators which have
not been determined locally by Mid Essex
Hospital Services NHS Trust.
Basis for qualified conclusion
We are satisfied that the Quality Account
meets the requirements set out in regulations
with the following exceptions:
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 determine such information, as well
as the measurement criteria and the
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• Regulation 4 - The Quality Account
does not include all of the mandatory
information set out in the schedule
attached to the regulations (as
amended for 2012/13). The omitted
mandatory information is as follows:
>> The number of different types of
relevant health services provided or
sub-contracted by the provider during
the reporting period, the number of
these relevant health services for which
data relating to the quality of care has
been reviewed and the percentage of
the provider’s income represented by
these services
>> A statement regarding whether or
not the provider has taken part in any
special reviews or investigations by the
CQC under section 48 of the Health
and Social Care Act 2008 during the
reporting period
>> Whether or not during the reporting
period the provider submitted records
to the Secondary Uses service for
inclusion in the Hospital Episodes
Statistics which are included in the
latest version of those Statistics
published prior to publication of the
relevant document by the provider
>> Some of the performance
information presented in the report has
not been obtained from the Information
Centre as required by the regulations.
Where an alternative source has been
used, the Trust has not clearly disclosed
this nor is there any explanation as to
why the departure from the regulations
has been necessary.
• Regulation 5 - The draft Quality Account
was significantly revised after the
statements from partner organisations
were provided. The regulations require
that an explanation of these revisions
be included in the final version of the
Quality Account but this has not been
included.
• Regulation 12- Our findings in 2012/13
illustrate that the Trust do not have
a robust mechanism in place to both
identify and act appropriately upon
guidance issued by the Secretary of
State in relation to chapter 2 of the
Health Act 2009.
We have read the information in the Quality
Account and concluded, based on the work
undertaken to date, that it is not materially
inconsistent with our review of the specified
documents with the following exception:
• Payment by Results (PbR) coding
review - The Trust has incorrectly
presented data from the clinical coding
report in the Quality Account in relation
to same day chemotherapy admission/
attendances in outpatients. The Quality
Account shows 30% of spells reviewed
resulted in a change to the healthcare
resource groups (HRG). The clinical
coding report states that the percentage
of HRGs changed is 0%. The Trust has
also omitted data and findings relating
to Accident Et Emergency coding
(which resulted in two high priority
recommendations in the PbR clinical
coding report).
Qualified conclusion
Based on the results of our procedures, with
the exception of the matters reported in the
basis for qualified conclusion paragraph
above, 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.
David Eagles
for and on behalf of BDO LLP, statutory
auditor
Ipswich, UK
28 June 2013
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10 - Annex A : Participation in clinical audit
This Annex provides detailed information to support the Clinical Audit section of the Quality
Account
Table 1 Participation in national clinical audits and confidential enquiries
National Clinical Audit
Participation
April 2012 to Number /
March 2013 percentage
of cases
submitted*
Epilepsy 12 (RCPH National Childhood
Epilepsy Audit)
Neonatal intensive and special care (NNAP)
Head & Neck cancer (DAHNO)
Adult Critical Care (ICNARC CMPD)
Yes
100%
Yes
100%
Yes
No
100%
N/A
Yes
N/A
Yes
100%
Yes
Yes
Yes
100%
223 cases
100%
No
N/A
Yes
Yes
100%
45 cases
Yes
96%
Yes
Expect to
submit 100%
Potential donor audit (NHS Blood &
Transplant)
Acute Myocardial Infarction & other ACS
(MINAP)
Cardiac Rhythm Management Audit
Heart Failure Audit
National Comparative Audit of Blood
Transfusion: Audit of blood sampling and
labelling
National Adult Diabetes Audit
National Parkinson’s Audit
British Thoracic Society: Paediatric Asthma
British Thoracic Society: Paediatric
pneumonia
British Thoracic Society: Adult community
acquired pneumonia
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Rationale for non
participation
During 2012/13 the
Trust was unable
to participate in
this data collection
due to resource
and IT issues.
These issues have
been resolved for
2013/14.
Due to IT issues the
trust was unable
to submit data
for this audit. It is
anticipated this
will be resolved for
2013/14.
Data submission
open until end of
May 2013
National Clinical Audit
Participation
April 2012 to Number /
March 2013 percentage
of cases
submitted
British Thoracic Society: Non-invasive
ventilation - adults
Yes
British Thoracic Society: Adult asthma
British Thoracic Society: Bronchiectasis
British Thoracic Society: Emergency use of
oxygen
No
No
No
National Cardiac Arrest Audit
National Audit of Dementia
National Oesophago-gastric Cancer Audit
National Lung Cancer Audit
National Bowel Cancer Audit Programme
Paediatric Fever (College of Emergency
Medicine)
Renal Colic (College of Emergency Medicine)
Hip, knee and ankle replacements (National
Joint Registry)
Inflammatory Bowel Disease Audit
Yes
Yes
Yes
Yes
Yes
100%
100%
100%
100%
100%
Yes
Yes
100%
100%
Yes
No
100%
N/a
Renal Replacement Therapy (Renal Registry)
National Review of Asthma Deaths
Yes
Yes
100%
100%
RCPH National Paediatric Diabetes Audit
National Vascular Registry: Carotid
Interventions Audit
National Vascular Registry: Peripheral
vascular surgery (VSGBI)
Yes
100%
Yes
30 cases
Yes
37
Sentinel Stroke National Audit Programme
Acute stroke
Yes
SINAP:
202 cases
Rationale for non
participation
Expect to
Data submission
submit all
open until end of
relevant cases May 2013
The British Thoracic
Society make
several audits
available annually,
the Trust is unable
to contribute to
all of these and
so must prioritise
those that have the
greatest potential
to impact on patient
care.
SSNAP:
100%
Trauma Audit & Research Network
Yes
65%
National Hip Fracture Database
Yes
100%
Participation to
resume 2013/14
2 cases reported to
date
Data submission
closed December
2012 – superseded
by SSNAP
Data entry is still in
progress
* Where the number of eligible patients is know, the percentage submission is reported. Alternatively the number
of cases submitted is reported.
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National Confidential Enquiry into Patient
Outcome and Death
Participation April 2012 to March 2013
Alcohol Related Liver Disease Study
Subarachnoid Haemorrhage Study
Tracheostomy Care Study
Yes
Yes
Yes
Table 2 Improving services following national clinical audit
National Clinical Audit
Improvements made, or to be made
Neonatal intensive and special care (NNAP)
The Trust reviewed the report published in
July 2012 in detail. The report indicated that
the Trust performance met or exceeded the
national average in all but one indicator. This
issue relates to data completion rate of the
first “Retinopathy of Prematurity” screening
for premature babies. Data entry error was
identified and to address this issue the Team
have introduced more robust processes for
monitoring and documenting which babies
need to be tested and when this has been
completed.
National Falls & Bone Health Audit
The Trust has taken the following actions
following the publication of May 2012 report:
1.Recruitment of another orthogeriatric
consultant leading to
a. Achievement of best practice tariff for hip
fractures.
b. Improved bone health assessment and
prescribing of drugs to promote bone health.
c. Early detection and management of delirium
d. Consultant driven rehabilitation and
discharge planning.
2. Formulation of inpatient falls risk
assessment policy, and post fall management
plan, leading to increased awareness and
higher incidence of reporting of inpatient falls.
3. Setting up of community geriatrician led
falls clinics in primary care settings.
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National Clinical Audit
Improvements made, or to be made
Heavy menstrual bleeding (RCOG National Audit
of HMB)
This national audit was done to ascertain
how long women had suffered from HMB
before hospital referral and what treatments
they received in primary care. The data we
provided from MEHT demonstrated a 37%
rate of case ascertainment, which is in the
upper quartile for all participating NHS Trusts
– this figure demonstrates the level of Trust
involvement with the audit project. In addition,
the results of this national audit (second
annual report) suggest that approximately 2/3
received treatment for HMB in the primary
care setting.
In order to take the results of this study
forward we are embarking on a GP study
day to update local GPs about the treatment
of HMB in the primary care setting. This
study day is recognized by the RCGPs and
will also include an update on other aspects
of obstetrical/gynaecological care in the
community.
National Heart Failure Audit: the treatment of
heart failure patients in UK hospitals from April
2011-March 2012
This looks at the proportion of patients who
get echocardiography, receive appropriate
drug therapy in hospital and get referred to a
community clinic for follow up. Evaluation of
this national database indicates the enormous
effect of drug therapy on survival for 1 and
3 years after admission. In addition, good
medical therapy has been shown to reduce
readmissions.
Our results indicate excellent performance
against the national standards. This has
been achieved through the hard work of our
cardiac nurse practitioners. We will continue
to develop this service and our links with the
community team.
Myocardial Infarction National Audit Project
(MINAP)
The report indicates that the Trust met or
exceeded national averages for standards
relating to the provision of secondary
prevention medication. Non-ST-segmentelevation myocardial infarction is a type of
heart attack. For this aspect of care, the Trust
exceeded the standard for patients being seen
by a Cardiologist or member of Cardiology
Team however this was often in an emergency
assessment ward rather than a cardiac ward
due to the configuration of services.
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National Clinical Audit
Improvements made, or to be made
National Comparative Audit of Blood
Transfusion: Audit of blood sampling and
labelling
The audit report was reviewed and as a result
the blood transfusion request form has been
changed to identify the sample taker more
clearly.
National Comparative Audit of Blood
Transfusion: Medical use of blood
A full final audit report incorporating the
findings of Part 1 and Part 2 is due for
publication in April 2013 and will contain a
detailed list of recommendations. Part 1 has
been published in advance and whilst this
indicates that much of transfusion practice
was found to be appropriate there was a
need to ensure haemoglobin levels were
checked prior to transfusions to ensure these
interventions were indicated.
National Adult Diabetes Audit
The 2012 report was reviewed in detail within
the Trust. This review identified that apparent
poor performance related to issues with
the data submission rather than indicating
inappropriate levels of care. The submission
process is being amended for 2013 so that the
findings can help drive improvement.
National Cardiac Arrest Audit
National Cardiac Arrest Audit data is sent
to the Trust quarterly. These reports are
reviewed at the Patient at Risk meetings
and the Trust’s performance is in line with
peer organisations. Any recommendations
implemented.
National Audit of Dementia
The report of the second round of the National
Dementia Audit has been reviewed and an
action plan developed by a multi-professional
team to address areas of poor compliance.
Key will be the development of an inpatient
care pathway for patients with Dementia.
National Oesophago-gastric Cancer Audit
This is an on-going national audit of
the results of treatment for gastric and
oesophageal cancer. All patients diagnosed
with these cancers are entered prospectively.
The 2012 report is the third to date and
the surgical results from MEHT (serving a
population of 1.8 million people) have been
consistently better than the national average
in all three reports. We have not been so
good however in entering data for patients not
undergoing surgery (eg those having palliative
chemotherapy or stents). This is, at least
partly, due to the lack of any data support
to the Upper GI team. The excellent results
that we have achieved so far are in large part
due to the strong team approach with joint
operating by the surgeons and a very strong
CNS team.
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National Clinical Audit
Improvements made, or to be made
National Lung Cancer Audit
This report covers patients diagnosed
with lung cancer in 2011. The data allow
benchmarking of the service at MEHT against
national performance as well as at the level
of the Essex Cancer Network. The number
of cases of lung cancer diagnosed at MEHT
continues to rise, with 190 in 2011. Where
indicators were below the national average,
the service has undergone a period of
transition and work is being done to improve
the figures. Early data for 2012 suggest
improvement. The quality of data submitted
from MEHT has been poor in the past but is
also improving thanks to hard work and a new
database system. MEHT will be more active
in participating in ECN Lung TSSG network
audits in the future. These are an effective
method for improving care quality.
National Bowel Cancer Audit Programme
Constant update and comparative audit
with other organisations – usually via Essex
Cancer network
National Pain Audit
The Trust reviewed the report and was
complaint with the majority of the standards
providing a multimodal pain service for
patients that includes acupuncture and
cognitive behaviour therapy. The key
outstanding issue is the involvement of clinical
psychologists in the multidisciplinary team
and a business plan has been developed to
address this.
A&E Consultant Sign Off (College of Emergency
Medicine)
Audit showed that we are partially compliant
(71%) but better than national average of
44%. Sustained emphasis and support is
being provided at various forums.
The audit has highlighted areas for
improvement in standards such as early
diagnosis, high flow oxygen, early IV fluids,
blood gas, IV antibiotics and cultures
prior to antibiotics. The results have been
communicated to the staff. Sustained
emphasis and support is required and is being
put in place.
Severe sepsis & septic shock (College of
Emergency Medicine)
The audit has shown that our initial pain
management is better than recommended
however the re-assessment of pain needs
improvement. A stamp acting as a prompt for
subsequent assessment has been introduced
since and is expected to demonstrate
improvement.
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National Clinical Audit
Improvements made, or to be made
Pain management (College of Emergency
Medicine)
The audit has shown that our initial pain
management is better than recommended
however the re-assessment of pain needs
improvement. A stamp acting as a prompt for
subsequent assessment has been introduced
since and is expected to demonstrate
improvement.
National Vascular Registry: Carotid Interventions
Audit
The Trust has significantly improved since
this audit was undertaken and gone through
considerable change that has enabled the
vascular service to increase efficiency and it is
now meeting the recommendation.
Sentinel Stroke National Audit Programme Acute
stroke (SINAP)
The Trust reviewed the Organisational report
published in 2012. This has identified that
staffing levels and training provision should be
reviewed.
Trauma Audit & Research Network
Historic issue with part time data entry support
in place, improved processes for identifying
those records that need to be screened.
Next task is to raise return rate. Reports are
disseminated and indicate high survival rates
following traumatic injury.
Hip, knee and ankle replacements (National
Joint Registry)
The report indicates that the Trust’s level of
data submission and completeness for the
National Joint Registry are of a very high
standard. The associated Patient Reported
Outcome Measures (PROMS) for the Trust’s
hip and knee operations indicate excellent
outcomes.
National Hip Fracture Database
The report indicates that for several
parameters the Trust exceeds national levels
of performance. For example the Trust is
8th best in the country [8 out 184 hospitals]
for length of stay in hospital and patients
returning to their home post operatively and
above average for;
• Patients having surgery within 36hrs
• Patients having been assessed by Ortho
geriatric Consultant
• Patients having had bone health
assessments
National Confidential Enquiries
Improvements made, or to be made
Cardiac Arrest Procedures: Time to Intervene?
This scope of this report relates directly to the
work the Trust is undertaking to ensure that
patients are monitored appropriately, medical
intervention occur quickly when a patient’s
condition deteriorates and patients for whom
resuscitation is inappropriate are identified to
avoid distressing and unnecessary interventions.
The report has been reviewed in detail and a
number of initiatives have been implemented
to address the issues including launch of the
Trigger Response Team, ward based team
training in management of deterioration and
competency assessment of Health Care Support
Workers taking patient observations.
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Table 3 Improving services following local clinical audit
Local Audit
Actions taken
Potential Harm audit
Inpatient areas within the Trust collect
weekly data on key patient safety and quality
issues. This on-going audit programme has
helped sisters on the wards to take action
quickly where any issues were identified: this
included raising issues with their team at ward
meetings or speaking with individuals directly.
Similarly the Chief Nurse reviewed the data
weekly and discussed any concerns with
senior nurses.
Patient Observations audit and unplanned
admissions to the Intensive Care Unit
Taking regular and accurate patient
observations and acting when a patient starts
to deteriorate is essential to the delivery of
high quality safe care. This aspect of care
remains one of the Trust’s priorities and so
a detailed audit was undertaken in each
quarter of 2012/13. During this period, the
standard of documenting physiological
observations improved significantly. The
information from these audits has been
used to inform the development of various
initiatives to drive improvement including the
introduction of a Trigger Response Team, a
revised observation chart and a new patient
observations competency assessment for
Health Care Assistants.
Patient assessment for the risk of falls
Like many acute hospitals, a high number of
the admitted patients are elderly or confused
and as such are often at increased risk of
falling in unfamiliar surroundings. Reducing
the likelihood and severity of harm is therefore
a key priority for the Trust and so every adult
patient has a risk assessment undertaken
on admission. Regular audit is undertaken to
make sure that this process is undertaken in a
timely way and that where risks are identified
appropriate actions are taken.
As a result of an earlier cycle of this audit, a
new risk assessment tool was developed. This
improved the quality of the patient assessment
significantly but there was still room for
further improvement and so the care plan that
records the measures in place to minimise
the risk of falling was revised and launched in
January 2013.
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Local Audit
Actions taken
Patient assessment for Moving and Handling
risks
Moving and handling of patients is an
important patient safety and staff issue.
Effective moving and handling plans must be
developed to minimise the risks for patients
and staff.
An audit of compliance with completing these
risk assessments took place regularly to make
sure they were completed in a timely and
effective way and to ensure that any required
equipment is available. The assessment tool
has now been included within the revised
patient admission booklet so that key risk
assessments are all held in one document.
Do not attempt resuscitation audit
When patients suffer a cardiac arrest in the
hospital, a special call is initiated to ensure
that the right team attends the patient
urgently to attempt resuscitation. For those
few patients where resuscitation is not
appropriate, our medical staff must ensure
that appropriate documentation is in place
so that distressing and inappropriate medical
interventions do not occur.
An audit was undertaken to assess the
quality of this documentation in May 2012.
This identified that the Do Not Attempt
Resuscitation form was easier to locate,
signed off appropriately with the reason for the
decision documented more often than in the
last cycle of audit.
There was still room for improvement in other
areas such as documenting a review date
and that the nursing team were informed of
the decision. The findings of the audit were
shared with the clinical teams and the Trigger
Response Team who attend patients who are
starting to deteriorate are helping to address
this. The audit will be repeated in 2013 to
check that performance has improved.
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Local Audit
Actions taken
Clinical record keeping audit
Good quality medical records are essential
to the delivery of effective healthcare. They
help the multidisciplinary team with ensuring
the continuity of care describing all the plans,
treatments and interventions put in place
during a patient’s admission.
This audit is undertaken annually to assess
the quality of the documentation and in
2012, levels of compliance were generally
very good. Where there were concerns each
clinical area was asked to review its findings,
and feedback any issues to their staff and if
necessary develop their own local actions to
improve the quality of the records.
Consent audit
Before starting a treatment or physical
investigation, the clinician must obtain valid
consent from the patient. This legal and
ethical principle reflects the right of patients’ to
determine what happens to their own bodies,
and is fundamental to good practice.
The health professional taking consent should
be competent to undertake the procedure
or be competent tell the patient about the
procedure and answer any questions they
have. The consent process is documented on
the consent form or in the medical records.
Audits in 2012 have identified that we
need to improve some of the associated
documentation. As a result the Trust is
developing better records of who is competent
to take consent for particular procedures and
staff have been reminded to document the
written information given to patients.
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Local Audit
Actions taken
Patient information audit
The provision of high quality written information
can have a significant impact on a patient’s
experience during a hospital visit. The Trust
makes a wide range of procedural information
available to clinicians and patients, most of
which is provided by a company specialising in
this area.
An audit is undertaken each year to check that
the locally generated information leaflets are
registered and contain relevant information. In
2012 the audit found some available leaflets
did not meet these standards and so clinical
teams were made aware and asked to update
those leaflets.
Management of patients with Venous
Thromboembolism (VTE)
The aim of this audit was to establish whether
the treatment of patients with established
venous thromboembolism follows local and
national guidance. The audit found that
Thrombolysis was administered appropriately
in all cases where it was used and that the
target INR, an indicator of blood thinning to
prevent further clots developing, was reached
prior to discharge or the patient was discharged
on Low Molecular Weight Heparin in all cases.
Blood Transfusion audit
Some patients require a transfusion of donated
blood as part of their treatment. This is very
effective when it is needed but there are
known risks associated with blood transfusions
and it is essential that appropriate checks
are undertaken prior to, during and after the
administration of the blood or blood products.
A regular audit is undertaken to assess levels
of compliance with these requirements. The
findings in 2012 showed that performance had
improved from 2011 however to ensure this
performance was maintained a monthly mini
audit of 5 ward areas was continued and staff
were reminded of the importance of attending
the relevant training sessions and documenting
patient observations prior to, during and at the
end of the transfusion.
Medical equipment competencies
68
It is important that when new members of staff
start work they are provided with training in
the use of relevant medical devices. Regular
audit of new starters took place throughout
the year and there was evidence of significant
improvement in performance over the period.
However it was recognised that this process
need to be reinvigorated and as a result a task
and finish multidisciplinary group has been
established to review the processes and drive
further improvements.
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11 - Annex B : Comments from partner
organisations
of announced and unannounced visits
throughout the year.
MECCG Response to MEHT Quality
Account 2012/2013
This is the first year that Quality Accounts are
being commented on by Mid Essex Clinical
Commissioning Group (MECCG) as the main
commissioner of services provided at Mid
Essex Hospital Services NHS Trust (MEHT).
MECCG welcomes this Quality Account as a
commitment to an open and honest dialogue
with the public regarding the quality of care in
MEHT. Assurance from MECCG is required
to ensure that the information in this Quality
Account is accurate, fairly interpreted, and
representative of the range of services
delivered.
Though MECCG is commenting on a draft
version of this Quality Account, it is pleased
to be able to assure the accuracy of the
content in general. MECCG is however
unable to assure all data reported, as
some data will have been updated prior to
publication.
You describe processes to monitor your own
progress through the year, these appear
robust. In your account you also celebrate
your quality achievements, and as necessary
working through any issues that might have
arisen in relation to delivering against the
priorities for the last year. You give an outline
summary of actions taken in the past twelve
months and your vision for the year to come.
You use views and comments from users
of your services to illustrate areas of good
practice.
MECCG notes the areas of concern
highlighted by the Care Quality Commission
(CQC) and will particularly monitor progress
of those areas and maintain a programme
Your areas for improvement in 2012 – 2013,
have been supported by MECCG through
agreement of CQUIN schemes, which
provide financial incentives to improve quality
and your achievement against the majority
of those schemes is noted. Also, your
recognition of where further work needs to be
undertaken, especially in the elimination of
avoidable pressure damage.
You give a comprehensive description of
your participation in and learning from clinical
audit. You give a summary of findings and
learning from all clinical audits undertaken.
In your report there is information about your
performance in respect of data quality and
the improvements you have made in the last
twelve months, with a concerted effort made
to ensure that the vast majority of staff have
received training by March 2013in order to
meet level 2 criteria within the Information
Governance (IG) toolkit.
We note your performance in relation to
SHMI has remained within the control limits
for this reporting period. It is noted however
that the SHMI, whilst remaining within
control, has been on an upward trajectory.
Your Quality Targets for 2013 - 2014 are:
• To improve patient safety
• To reduce hospital acquired infections
in line with national and local targets
• To improve clinical outcomes and
effectiveness
• To continuously improve the
experiences of service users and their
families and/or carers
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Whilst continuing to improve on areas
identified for 2012/13.
MECCG supports your choice of priorities.
In conclusion the MECCG considers Mid
Essex Hospital Services NHS Trust Quality
Accounts for 2012 - 2013 as providing
an accurate and balanced picture of the
reporting period. MECCG encourages the
Trust to continue to implement the multiple
and wide-ranging efforts and initiatives to
improve the quality of its services.
We share the aspiration of making the NHS
more patient-focussed and placing the
patient’s experience at the heart of health
and social care. An essential part of this
is making sure the collective voice of the
people of Essex is heard and given due
regard, particularly when decisions are being
made about quality of care and changes to
service delivery and provision.
Statement from Healthwatch Essex for
Quality Account report 2012-2013
Our wish is therefore that Healthwatch Essex
works with its partners in the health and
social care sector to engage patients and
service users effectively and to ensure that
their views are listened to and acted upon.
We look forward to working together in the
production of Quality Accounts in the coming
year and making sure that the voice and
experience of patients and the public form
an integral part of these documents. At a
time when the NHS is facing great change
and financial challenge, patient experience
and quality of care are more important than
ever, and we welcome the opportunity to help
shape the NHS of the 21st century.
We recognise that Quality Account reports
are a useful tool in ensuring that NHS
healthcare providers are accountable to
patients and the public about the quality
of service they provide. We fully support
these reports as a means for providers to
review their services in an open and honest
manner, acknowledging where services are
working well and where there is room for
improvement.
We welcome the opportunity to provide
a patient and public perspective on the
Quality Accounts. As a newly-established
organisation (we took on statutory
responsibility on 1st April 2013), we are not in
a position to comment retrospectively on the
findings of the past year. We will, however,
cooperate fully in the future production
of these reports. We are an organisation
which intends to provide comment rooted in
evidence – be it ‘soft’ intelligence or more
extensive, quantitative data. Following
the Francis Report, we believe there is a
significant challenge and opportunity for
the whole health and social care system
70
to look at how evidence relating to patient
experience can be set on an equal footing
with standard NHS data about performance
and quality.
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Mid Essex Hospital Services NHS Trust - Quality Accounts 2012 | 13
in treating and caring for me, as I believe I
only survived this illness due to the Doctors
quick diagnosis and giving me the correct
treatment, plus the very good nursing care I
received to get me well again”
Extracts from letters from our patients
and visitors
“Thanks so much for helping my mummy.
Also thank you for letting me be a Nurse”
“My husband and I received the very best
care and support during his stay and we
cannot truly thank them enough”
“Right through from Reception to Surgeon to
Anaesthetist to Nurses I received first class
treatment involving courtesy, friendliness and
professionalism”
“I thought I ought to write and commend the
work of the people I came into contact with
at the hospital. Everyone I encountered was
extremely professional and treated me with
the upmost care and respect. They are a real
credit to the National Health Service”
“As an acknowledged coward in this area
of life experiences, I had anticipated a
very stressful and fearful day. However
due to your friendly, good humoured and
professional staff, my few hours at the unit
turned out to be a very pleasant experience
(save of course the operation itself). I was
put at ease, advised continually of what was
happening and at no time did I feel ignored,
uninformed or a nuisance”
“In the time leading up to the operation, it
was necessary to visit various departments
within the hospital and again at each stage I
found appointments were efficiently arranged
and I was always treated with the greatest
courtesy from everyone involved”
“I wanted to write to you as these are the
people who are in the background but who
put themselves out that evening to help me
deal with a very stressful situation”
“The second reason is to praise the general
attitude of staff throughout the hospital. In
all departments the standards of customer/
patient care have been excellent. No matter
how busy the staff are, they have always
been, respectful helpful and courteous”
“I am writing to you as Chief Executive, to let
you know what brilliant care I received. I did
not want to single anyone out as every one
of your staff I encountered was hardworking,
cheerful, helpful, caring and kind. This
applies to all the staff form surgeon down,
nurses, assistant nurses, trainee nurses,
physiotherapists, porters, caterers, cleaners
etc”
“I would like you to pass on my gratitude
and thanks to all the staff that were involved
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12 - Annex C : Statement of Directors’
responsibilities in respect of the Quality Accounts
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 and 2012).
In preparing the Quality Account, directors are required to take steps to satisfy themselves that:
• the Quality Accounts 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
hguidance.
The directors confirm to the best of their knowledge and belief they have complied with the
above requirements in preparing the Quality Account.
By order of the Board
24th June 2013............................................................Chair
.24th June 2013............................................................Chief Executive
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13 - Glossary of Terms
ACE inhibitor
Commissioning for Quality & Innovation
(CQUIN)
medicines that are used mainly in the treatment
of hypertension (high blood pressure) and heart
failure.
the CQUIN payment framework is a national
framework for locally agreed quality improvement
schemes. It makes a proportion of provider
income conditional on the achievement of
ambitious quality improvement goals and
innovations agreed between commissioner and
provider, with active clinical engagement. The
CQUIN framework is intended to reward genuine
ambition and stretch, encouraging a culture of
continuous quality improvement in all providers.
In order to earn CQUIN money, providers of
acute, ambulance, community, mental health
and learning disability services using national
contracts must agree a full CQUIN scheme
with their commissioners. CQUIN schemes are
required to include goals in the three domains
of quality: safety, effectiveness and patient
experience; and to reflect innovation.
Care Quality Commission (CQC)
the independent regulator of health and social
care in England. The CQC regulates care
provided by the NHS, local authorities, private
companies and voluntary organisations.
Clostridium difficile
a spore-forming bacterium which is present as
one of the normal bacteria in the gut of up to
3% of healthy adults. People over the age of 65
are more susceptible to developing illness due
to these bacteria. C Difficile diarrhoea occurs
when the normal gut flora is altered, allowing
C Difficile bacteria to flourish and produce a
toxin that causes watery diarrhoea. Procedures
such as enemas, gut surgery, and drugs such
as antibiotics and laxatives cause disruption of
the normal gut bacteria and increase the risk of
developing C Difficile diarrhoea.
Department of Health
the department of the UK government
responsible for policies on health, social care and
the NHS in England.
Clinical audit
measures the quality of care and services
against agreed standards and suggests or makes
improvements where necessary.
Clinical coding
clinical coding officers are responsible for
assigning a code for every inpatient stay and
day case visit (or ‘episode’). The coding process
enables patient information to be easily sorted for
statistical analysis.
Dr Foster
Dr Foster is an independent organisation
dedicated to making information about the
performance of hospitals and medical staff as
accessible as possible.
Failure to rescue
a failure in the recognition or management of a
patient whose condition deteriorates.
Francis Report
Comfort rounds
nurses proactively visiting patients on an hourly
basis, in addition to their usual rounds.
Commissioners
organisations that buy services on behalf of
people living in a defined geographical area.
They may purchase services for the population
as a whole, or for individuals who need specific
care, treatment and support.
In June 2010 the Secretary of State for Health,
announced a full public inquiry into the role of
the commissioning, supervisory and regulatory
bodies in the monitoring of Mid Staffordshire
Foundation NHS Trust. The Inquiry was chaired
by Robert Francis QC, and reported to the
Secretary of State making recommendations
based on the lessons learnt from Mid
Staffordshire.
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Global Trigger Tool
NHS Number
The Institute for Healthcare Improvement’s (IHI)
Global Trigger Tool for measuring adverse events
provides a useful method for identifying adverse
events and measuring the rate over time. The
trigger tool methodology uses a retrospective
review of randomly-selected patient records
using triggers (or clues) to detect adverse events.
the only national unique patient identifier, used to
help healthcare staff and service providers match
you to your health records.
Healthcare Associated Infection
an avoidable infection that occurs as a result of
the healthcare that a person receives.
Local Involvement Networks (LINks)
made up of individuals and community groups,
such as faith groups and residents’ associations,
working together to improve health and social
care services.
National Institute for Health Research (NIHR)
maintains a health research system in which the
NHS supports outstanding individuals conducting
leading edge research focused on the needs
of patients and the public. It is funded through
the Department of Health to improve the health
and wealth of the nation. Costing Templates
are required documents for any research and
development submission and are used for
generating commercial study costs to provide
cost transparency and predictability when
negotiating local site budgets.
NEVER EVENT
Joint Health Scrutiny Committee (known as
Overview and Scrutiny Committees (OSCs)
since January 2003, every local authority with
social services responsibilities has had the power
to scrutinise local health services. OSCs take on
the role of scrutiny of the NHS – not just major
changes but the ongoing operation and planning
of services. They bring democratic accountability
into healthcare decisions and make the NHS
more publicly accountable and responsive to
local communities.
MRSA
MRSA (Methicillin Resistant Staphylococcus
Aureus) is an antibiotic-resistant form of a
common bacterium called Staphylococcus
Aureus that can cause infection in a range of
tissues such as wounds, ulcers, abscesses or
bloodstream. Staphylococcus Aureus is found
growing harmlessly on the skin in the nose in
around one in three people in the UK.
National Confidential Enquiry into Patient
Outcome and Death (NCEPOD)
They have published 30 reports looking at
specific aspects of care and identifying best
practice through detailed case note review of the
management of patients.
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these are serious patient safety incidents
identified at a national level that should not
occur as the risks are known and preventative
measures available.
Net Reporter
The Net Promoter Score is obtained by asking
patients a single question, “How likely is it
that you would recommend this service to
friends and family?” Based on their responses,
customers are categorised into one of three
groups: Promoters, Passives, and Detractors.
The percentage of Detractors is then subtracted
from the percentage of Promoters to obtain a
Net Promoter score (NPS). NPS can be as low
as -100 (everybody is a detractor) or as high as
+100 (everybody is a promoter).
Primary Care Trusts (PCTs)
with responsibilities for improving the health of
the community, developing primary.
Productive Ward Programme
The Productive Ward (releasing time to care)
focuses on improving ward processes and
environments to help nurses and therapists
spend more time on patient care thereby
improving safety and efficiency.
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PROMs
Research
Patient Reported Outcome Measures (PROMs)
measure quality from the patient perspective.
Initially covering four clinical procedures, PROMs
calculate the health gain after surgical treatment
using pre and post-operative surveys.
clinical research and clinical trials are an
everyday part of the NHS, and often conducted
by medical professionals who also see patients.
A clinical trial is a particular type of research
that tests one treatment against another. It may
involve either patients, or people in good health,
or both.
Quality Domains
the Government Paper, High Quality Care for All,
published in June 2008, defined 3 domains of
quality:
Patient Safety - doing no harm to patients
Clinical effectiveness - measured
using survival rates, complication rates,
measures of clinical improvement, and patientreported outcome measures
Patient experience - care should be
characterised by compassion, dignity and respect
Quality Intelligence East (QIE)
a unit within the eastern regions that focuses
on providing information on quality of clinical
services and works with NHS clinicians and
managers to identity areas where health services
can be improved.
Quality, Innovation, Productivity & Prevention
(QIPP) programme
an opportunity to prepare the NHS to defend and
promote high quality care in a tighter economic
climate. QIPP focuses on the NHS working in
different ways to ensure that the highest quality
care is delivered. It encourages efficiency and
focuses on a ‘joined up’ approach to delivering
healthcare.
The Quality & Risk Profile (QRP)
is tool used by the CQC for gathering together
key information about trusts to support how they
monitor compliance with the essential standards
of quality and safety. The QRP enables CQC
compliance inspectors to assess where risks lie
and may prompt further enquiries.
Root Cause Analysis (RCA)
a structured investigation of an incident to ensure
effective learning to prevent a similar event
happening. Safety Express: National safety
initiative targeted towards high impact areas as
part of the QIPP programme. The focus includes
pressure ulcers, catheter care, VTE and falls.
SBAR – this stands for Situation
Background, Assessment, Recommendation.
It is an easy to remember mechanism to frame
conversations, especially critical ones, requiring
a clinician’s immediate attention and action. The
SBAR tool consists of prompt questions within
four sections, to ensure that staff are sharing
concise and focused information effectively.
Thrombolysis
this means dissolving blood clots by injecting a
special clot-dissolving drug into the artery directly
into the blood clot. This can lead to a marked
improvement in blood flow and may avoid the
need for an operation. Once a clot starts to form
in a blood vessel it may carry on getting bigger
until the whole vessel is blocked. Although the
blood clot can be removed by an operation, it is
also possible to dissolve the clot.
Venous thrombo-embolism (VTE)
a condition in which a blood clot (thrombus)
forms in the vein. These blood clots are a known
complication of immobility and surgery.
WHO Surgical Checklist
Risk Assurance Frameworks
documents that map out risks to Directorates
or the Trust achieving their objectives and the
progress with actions developed to address
these risks.
Ensure that a checklist is completed for every
patient undergoing a surgical procedure
(including local anaesthesia). Ensure that the
use of the checklist is entered in the clinical notes
or electronic record by a registered member of
the team.
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