Quality Report
April 2012 – March 2013
Care for
People
Work
Together
Listen
and
Improve
Do the
Right
Thing
Mid Staffordshire NHS Foundation Trust
Quality Report
April 2012 – March 2013
April 2012 – March 2013
Quality Report
Contents
Quality Report ................................................................................................................................. 3
1.
Statement on Quality from the Chief Executive ........................................................................ 5
1.1
Purpose of the Quality Account ......................................................................................... 6
1.2
Quality & Safety Strategy 2011-2015 ................................................................................ 7
2.
Priorities for Improvement and Statement of Assurance from the Board .................................. 8
2.1
Priorities from 2012-2013 and Achievements .................................................................... 8
2.2
Priorities for 2013- 2014.................................................................................................. 11
2.3
Statements of Assurance from the Board........................................................................ 13
2.4
Audits Measuring Participation, Coverage and Review of Clinical Audits ........................ 14
2.5
Participation in Clinical Research .................................................................................... 20
2.6
Quality Indicators ............................................................................................................ 21
2.7
What Others Say About Mid Staffordshire NHS Foundation Trust................................... 24
2.8
Clinical Data ................................................................................................................... 26
2.9
National Health Service Litigation Authority (NHSLA) ..................................................... 29
2.10
Human Tissue Authority (HTA) Inspection Report ........................................................... 30
2.11
Quality Governance Framework ..................................................................................... 30
2.12
Safeguarding – Adults and Children................................................................................ 31
2.13
Equality and Diversity Update ......................................................................................... 32
2.14
Hospital Readmissions Rate Data................................................................................... 32
2.15
Performance against the Nationally Mandated set of Quality Indicators .......................... 33
3.
Other Information ................................................................................................................... 33
3.1
Patient Safety ................................................................................................................. 33
3.2
Clinical Effectiveness ...................................................................................................... 39
3.3
Patient Experience .......................................................................................................... 44
3.4
Staff Survey .................................................................................................................... 49
4.
Statement of Directors' Responsibilities In Respect of the Quality Report .............................. 52
Appendices ................................................................................................................................... 53
Appendix A - MSFT Performance against the Nationally Mandated set of Quality Indicators ........ 53
Appendix B – Care Quality Commission Core Standards .............................................................. 59
Independent Auditor’s Report on the Annual Quality Report ......................................................... 61
Stakeholders Commentary on the Annual Quality Report ............................................................. 65
Acronyms and Definitions ............................................................................................................. 71
Mid Staffordshire NHS Foundation Trust |
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| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
April 2012 – March 2013
Quality Report
Quality Report
Mid Staffordshire NHS Foundation Trust |
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Quality Report
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| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
April 2012 – March 2013
1.
Quality Report
Statement on Quality from the Chief Executive
The Quality Account is our opportunity to feed back on our performance against a number of
specific quality goals, and it is also an opportunity for me to record my thanks to the staff of Mid
Staffordshire NHS Foundation Trust for the care, compassion and professionalism with which they
treat our patients. I would like to assure the populations we serve that we try very hard to be better
every year, and to commit to treating our patients safely and with kindness.
Our vision is simply to be recognised as the safest and most caring NHS Trust in the UK.
MSFT is on a journey, and I am confident that we have made progress throughout 2012-2013 in
relation to the 3 key elements of patient safety, clinical effectiveness and patient experience. I
think that today we are a cleaner, safer, and kinder hospital than we have ever been, but we can
still improve in all those areas.
This report describes in some detail how we have performed against the objectives we agreed as
priorities for 2012-2013 and outlines those priorities we have set for the coming year.
The priorities for 2013-2014 reflect the needs of our patient population, the local population is also
getting older ‐ which increases the number of acutely unwell, confused and vulnerable patients we
are seeing. So, we need to reduce the number of falls, pressure sores and improve the care of our
patients with long term conditions and Dementia. The priorities are also organised around our five
key themes: creating a culture of caring, seeing zero harm as our target by keeping patients safe,
listening, responding and acting on what our patients and community are telling us, supporting our
staff to become excellent, giving responsibility but holding to account as well, and continuing to do
what we need to do to satisfy our regulators
I hope you find this report an interesting and informative document. I think it presents a fair and
balanced view of what we have achieved and what we hope to achieve this coming year.
To the best of my knowledge, the information contained in the following Quality Account is
accurate.
Mr Alan Bloom
Trust Special Administrator
Mrs Lyn Hill-Tout
Chief Executive
Date: 29 May 2013
Mid Staffordshire NHS Foundation Trust |
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Quality Report
1.1
April 2012 – March 2013
Purpose of the Quality Account
Mid Staffordshire NHS Foundation Trust Quality Account forms part of the Trust’s annual report to
the public. It describes our key achievements with regards to the quality and safety of patient care,
clinical effectiveness and patient experience for 2012-2013 and the progress that has been made
delivering improvements throughout the year. We also describe how we have performed against
the national quality targets and locally agreed CQUIN (Commissioning for Quality and Innovation).
Our assurance statements are made in light of the activities across the whole year. It also outlines
areas where we need to focus our improvement work. It also sets out 5 key quality priorities for the
year ahead.
The development of the Quality Account has involved identifying and sharing information across
the organisation, particularly with consultants, nurses, allied health professionals, quality and
governance teams, governors and non-executives.
Quality Vision for Mid Staffordshire NHS Foundation Trust
The overall objectives of Mid Staffordshire NHS Foundation Trust focus around
five
themes
specifically designed to bring the key areas of quality and safety to life within a local context. These
five themes have been consistent features over the last 3 years. These five key themes are:
1.
2.
3.
4.
Creating a culture of caring
Seeing zero harm as our target by keeping patients safe
Listening, responding and acting on what our patients and community are telling us
Supporting our staff to become excellent, giving responsibility but holding to account as
well
5. Continuing to do what we need to do to satisfy our regulators
Our CQUIN and 7 priorities for 2013-2014 are underpinned by these themes. In 2013-2014 we will
also push forward with the priorities identified in last year’s Quality Account, where some have
been achieved but now need to be sustained and in others where we have achieved some
improvement but still require more work.
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| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
1.2
Quality Report
Quality & Safety Strategy 2011-2015
We launched our Quality and Safety Strategy in January 2012, its core purpose is to improve the
quality and safety of patient care. In line with national policy we define quality as care that is safe,
effective and experienced by our patients in a positive way.
The Board is responsible for assuring the quality of care being delivered across all services
within the organisation through relevant evidence that quality and good health outcomes are
being
achieved throughout the organisation. The specific responsibilities of the Board are
threefold and our Quality and Safety Strategy supports the delivery of these:
1. To ensure that the essential standards of quality and safety (as determined by Care
Quality’s Commission’s registration requirements) are being met as a minimum by every
service that the organisation delivers, every day.
2. To ensure that the organisation is striving for continuous quality improvement in the
outcomes of every service it delivers.
3. To ensure that every member of staff that has a contract with patients, or whose actions
directly impact on patient care, is motivated and enabled to deliver effective, safe and
patient–centred care.
In order for the Board to ensure and monitor quality it needs to have the right structures and
processes in place and the right culture, with supporting values and behaviours and staff who are
appropriately trained. The Collective term used for these by Monitor and the National Quality
Board is ‘Quality Governance’. Our Quality and Safety Strategy is the vehicle to help us achieve a
sustainable future which is safe for every patient together with our aspiration for continuous quality
improvement. To help with the delivery of the strategy we agreed four strategic objectives which
provide operational direction over the lifetime of the strategy leading to 2015, these are:
1.
2.
3.
4.
Deliver high quality safe patient care
Listen to, involve and empower our patients and carers
Empower and skill our staff to continuously improve quality and safety
Become more efficient through quality improvements
Mid Staffordshire NHS Foundation Trust |
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Quality Report
April 2012 – March 2013
2.
Priorities for Improvement and Statement of Assurance
from the Board
2.1
Priorities from 2012-2013 and Achievements
This section sets out the actions taken during the year on the quality improvement initiatives which
were set for 2012-2013 and the progress made. The priorities identified for 2012-2013 were:
a. Delivery of the Seven CQUIN Initiatives (see CQUIN performance page 21).
b. Implement Falls Care Bundle
The Fallsafe Care Bundle for all patients includes:






Ask on admission about history of falls and fear of falling
Urinalysis on admission
Avoid new night sedation
Ensure call bell in reach
Ensure appropriate footwear in use
Bedrails: assessment of risks and benefits
We set out to implement the falls care bundle on those wards with the highest incidents of falls. In
total the care bundle has been implemented on 6 wards throughout 2012-2013. Further
implementation of the care bundle on the remaining adult wards will continue in 2013-2014.
c. Reduce the Incidence of Pressure Sores – zero tolerance of avoidable hospital acquired
pressure sores grade 2 to 4
We committed to one of NHS Midlands and East's five ambitions for 2012 which was to "Eliminate
avoidable grade 2, 3 and 4 pressure ulcers by December 2012." Avoidable pressure ulcers are a
key indicator of the quality of nursing care. Preventing them happening improves all care for
vulnerable patients. We actively engaged in the Strategic Health Authority’s Change Champion
Programme, however, the elimination of all avoidable pressure ulcers remains a quality challenge
to the Trust.
Number of Hospital Acquired
Pressure Ulcers
Hospital Acquired Pressure Ulcers 2010-2012
200
150
Grade 2
100
Grade 3
50
Grade 4
0
2010
2011
2012
Grade 2
151
124
86
Grade 3
20
21
31
Grade 4
0
3
2
Year
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| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
Quality Report
There has been a reduction in the overall number of pressure ulcers year on year with 119
reported in 2012 compared with 148 in 2011 and 171 in 2010. However the number of grade 3
pressure ulcers in 2012 increased, this is likely to be due to all pressure ulcers reported on the
Trust’s incident system are now verified by the Tissue Viability Team to ensure that all pressure
ulcers are accurately graded. The reduction in Grade 2, 3 & 4 hospital acquired pressure ulcers
was also a national CQUIN for 2012-2013. Acute Trusts were expected to demonstrate a reduction
in the rate of grade 2, 3 and 4 pressure ulcers per 10,000 bed days over the year, through an
agreed improvement plan and improvement in the proportion of risk assessments completed and
care plans in place and being implemented.
The Trust achieved an overall ratio of 10.18 pressure ulcers per 10,000 bed days; this was less
than the baseline set in April from the previous year’s data of 12.33 pressure ulcers per 10,000 bed
days. Overall 99.3% of patients had a pressure ulcer assessment undertaken within 6 hours of
admission to the Trust and of those patients assessed as being at risk of developing a
pressure ulcer 92.5% were cared for using an appropriate pressure ulcer care plan.
Trust-wide training on the assessment, grading and prevention/ management of pressure ulcers
has taken place throughout 2012. A Skin Care Bundle was implemented across the Trust in August
2012.
A new review process was also put in place for the Grade 3 and 4 Root Cause Analysis (RCA).
These are now presented at a Pressure Ulcer RCA meeting when the author of the RCA is
challenged around their investigation process, definition of avoidable and unavoidable pressure
ulcer and the action plan is reviewed as well as being commended for any actions to prevent
further occurrence of pressure ulcers. Following this all RCAs go to the Trust Incident Review
Group for agreement before sign off. Learning from RCAs is also shared across the organisation at
the ward managers and matrons meeting.
The elimination of avoidable hospital acquired pressure ulcers remains a priority for the Trust.
Reducing Hospital Acquired pressure ulcers has been included as a CQUIN for 2013-2014 and
we have agreed with the CCG a target for reduction of 25%. In order to achieve this target in
2013-2014 we will:



Continue to provide all nursing staff with training relating to the assessment, grading,
prevention and management of pressure ulcers.
Implement a pressure relieving mattress equipment library. This will ensure the prompt
delivery of pressure relieving equipment to the wards as the previous process of ordering
directly from the supplier caused delays in the mattresses being delivered.
Ensure that the outcomes from Grade 3/4 pressure ulcers RCAs are shared across the
nursing workforce through presentation and discussion at the Nursing Quality Group and
through discussion at Ward level meetings.
This will be monitored by monthly reporting to the Hospital Quality Assurance Committee and Trust
Board and monthly reports to the Clinical Quality Review Meeting chaired by the CCG.
d. Improvement Academy
We agreed that a key objective for 2012 was to change culture; one driver for this was the launch
of the “Improvement Academy” with the aim of growing an internal resource of staff that are
trained and become experienced in continuous improvement tools, empowering them to
systematically identify and resolve problems.
Mid Staffordshire NHS Foundation Trust |
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Quality Report
April 2012 – March 2013
The implementation of the Improvement Academy is essential to supporting our Trust themes and
enabling these goals to be achieved. The programme focuses on real problems across all areas of
the organisation from direct patient care and clinical service to support and back office functions.
Multi disciplinary groups work as a team to analyse the problem within a specific service, think
through solutions and implement change to improve patient experience and the quality of service.
Two cohorts of the Improvement Academy took place in 2012-2013. The Trust plans to run a
further 3 cohorts in 2013-2014.
e. Pilot ‘I want great care’ as a means of achieving patient feedback about treatment and
care
“I want great care” was piloted in some outpatient clinics in 2012 with success. The Director of
Patient Experience plans to extend this initiative throughout the hospital during 2013 in order to
achieve real time feedback on the work of individual medical staff.
f. Medicines Management – Reduce Medication Error Rate
Nationally one of the most frequently reported incidents in the NHS relate to the error rate in the
prescribing or administration of medicines to patients. The Trust undertook significant work in
relation to its medicine’s management in 2011. To build further on this work a locally determined
CQUIN aimed at improving the management of medicines within the Trust was implemented in
2012-2013.
1. All patients to have a treatment chart completed in full
This was achieved with all patients having had a treatment chart completed in full with the
Trust achieving 100%.
2. Medication errors- missed doses
Trajectories were set for 2012-2013 for the reduction in the number of patients who had
missed doses of medication without a medically justified reason. These targets were
very ambitious and although the target set for Q1 was achieved the stretched target for the
remaining part of the year was not achieved.
The reduction in omitted doses without a medically justified reason remains a key safety and
quality priority for the Trust and revised targets based on the evidence available in relation to
missed dose have been included in the Quality Contract for 2013-2014.
In order to reduce the number of medication omissions without a medically justified reason in 20132014 we will:


Continue to undertake monthly audits of medication omissions in all clinical areas.
Include medication omissions on the Ward Quality Dashboards to ensure that this
is owned and actions are taken by the ward managers at ward level
Medication omissions without a medically justifiable reason will be monitored by the Trust through
the monthly Performance Review
Committee, and Divisional Governance meetings as well as
via the monthly Contract Monitoring meetings with the commissioners.
SHA Medicines Management and Pharmacy Peer Review
In late 2011, the Trust invited NHS West Midlands to undertake a peer review of medicines
management and pharmacy services; this was carried out in March 2012.
The report was generally positive. It made clear that no immediate patient safety risks were
highlighted during the peer review. In fact the visiting team observed a range of good practice, and
found staff interested and engaged. All the staff they met were very helpful to the visiting team and
were congratulated on their commitment to both the Trust and to the delivery of good patient
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| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
Quality Report
care. The report noted 'it was clear that there has been considerable attention paid to the safe,
effective and appropriate use of medicines', and 'overall the visit was positive with evidence of a
clear focus for medicines management, a newly revised medicines policy and procedures for safe
medicines use and some evidence that these are embedded in practice.'
The review team offered a number of suggestions for the Trust to consider. These and other issues
raised in the report are part of an on-going Action Plan.
Pharmacy Aseptic Unit Audit
A quality assurance audit was carried out by ‘Quality Control North West’ based at Stepping Hill,
Stockport, on the Pharmacy Aseptic Unit on 24 January 2013. The previous audit took place on
23 February 2011. The audit was undertaken by Mrs J Hayes and is the Unit’s audit under EL
(97)52, against a range of standards.
Conclusions and Recommendations
The staff have made good progress since the last audit in closing out major noncompliances. However, there are still significant numbers of minor non-compliances carried
over from the previous audit. The department would benefit from some dedicated time for
addressing the development of a quality issues and the development of a robust Quality
Management System. The overall risk rating for the audit is ‘Low’.
g. Reduce the incidence of discharging patients with a retained intravenous cannula
In 2012-2013 there were 10 patients discharged from hospital with a retained cannula, this was 2
less than the 12 cases reported in 2011-2012. Since the introduction of two nurses checking as
part of the Discharge Checklist, there have been no patients discharged from the wards at the
Trust with a cannula insitu. However, there continues to be incidents where patients are
discharged from the Accident and Emergency Department with retained cannula. A two nurse
checking process before a patient is discharged has also been implemented in the Accident and
Emergency department in February 2013. The Trust will continue to work throughout 2013-2014 to
implement changes to ensure that patients are not discharged from the A & E Department with a
cannula.
In order to continue to reduce the number patients discharged from hospital with a retained
cannula in 2013-2014 the MSFT will:



Ensure that all staff use the Discharge Checklist in full.
Audit the Discharge Checklist to evaluate compliance with the 2 nurse checking for cannula
prior to discharge of the patient. The results of this will be fed back at Ward and Divisional
level via Ward meetings, Nursing Quality Group and the Nursing and Midwifery Strategy
Group.
Continue to ensure that the learning from RCA carried out following any patient discharged
with a retained cannula is embedded into clinical practice.
Reducing the incidence of discharging patients with a retained intravenous cannula will be
monitored by the Trust through the monthly Nursing Quality Group and the Nursing and Midwifery
Strategy Group, Performance Review Committee, and Divisional Governance meetings as well as
the Hospital Quality Assurance Committee and Incident Review Group.
2.2
Priorities for 2013- 2014
The priorities for 2013-2014 are outlined below. Three priorities continue from those set and
agreed by the trust Board in 2012-2013. All priorities were agreed by the Trust Board and
negotiated with our commissioners. They were chosen because they represent areas of concern or
incidents identified, because of the strategic direction identified within the Quality and Safety
Strategy and Business Plan or because they demonstrate evidence based best practice.
Mid Staffordshire NHS Foundation Trust |
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Quality Report
April 2012 – March 2013
a. Achievement of the 8 CQUIN initiatives
The CQUIN for 2013-2014 are detailed on page 21.
Reducing the incidence of hospital acquired pressure ulcers was a priority in 2012-2013 (see page
8) and remains a key priority for 2013-2014. The Trust has set a target of reducing hospital
acquired pressure ulcers by 20% for this year as part of the CQUIN agreed with the CCG.
CQUIN performance will be monitored monthly as part of the Quality Report submitted to the
Hospital Quality Assurance Committee and Trust Board. It will also be monitored at Performance
Review Committee and Divisional Governance meetings. Performance will also be monitored by
submission of quarterly reports to the Clinical Quality Review Meeting chaired by the CCG. The
Nursing Metrics included in the CQUIN for 2013-2014 are also monitored at the Nursing Quality
Group and Nursing and Midwifery Strategy Group held monthly.
b. Reduction in medication omissions without a medically justifiable reason
(See page 10).
c. Reduce the incidence of discharging patients with a retained intravenous cannula
(See page 11)
d. Reduce the number of adult inpatient falls.
The Trust has set a target to reduce falls by 14% in 2013-2014 in order to achieve a falls per 1,000
bed day’s ratio of 5.6% (this is the ratio recommended by the NPSA 2009). This was discussed
and agreed with our commissioners.
In order to achieve this we will:






Continue the implementation of the Falls Care Bundle on all adult inpatient wards (see
page 8)
Implement the Falls Strategy and Action Plan
Set a falls reduction target with the ward managers for each adult inpatient area and
include the reporting against this target as part of the Ward Quality Dashboards
Undertake audits of the Falls Risk Assessment and appropriate use of the falls care plan
Continue Falls training for nursing and Allied Health Care Professionals
Undertake a peer review process for falls management across the organisation (to be coordinated by the Director of Nursing)
The number of falls and implementation of the Falls Strategy and action plan will be monitored by
the Trust Falls Group. Performance will also continue to be monitored as part of the Quality and
Safety Report submitted to the Hospital Quality Assurance Committee and Trust Board, through
the monthly Performance Review Committee, Divisional Governance meetings as well as via the
monthly Contract Monitoring meetings with the commissioners.
e. Implement a new model of nursing leadership on all adult wards
MSFT will be implementing a model of nursing leadership on all adult wards which achieves
making the ward sisters as supervisory, and more able to ensure consistent improvements in
standards of care. The Trust Board has agreed that this is a priority recommendation from the
Francis Inquiry and must be implemented across the organisation. Funding has been agreed by
the Trust Investment Committee.
In order to achieve this we will:

12
Develop Key Performance Indicators (KPIs) for the Ward Sister’s which include
improvements in key quality indicators for their individual clinical areas and trajectories for
| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
Quality Report
improvement based on the individual ward’s performance in 2012-2013 against these
quality indicators.

Develop and implement a Ward Sister’s Development Programme to enable the ward
sisters’ to be supported and enabled to deliver on all quality aspects of care for their ward
areas.
The Ward Sister’s KPIs will be monitored via the Ward Quality Dashboards, at the Nursing Quality
Group, Nursing and Midwifery Strategy Group and HQAC which reports up to the Trust Board.
f.
Review of the Quality dimensions of the Francis Report and implementation of
measures to achieve local compliance where applicable
This is a key priority for MSFT. A Corporate Action Plan has been developed
with
Executive
Directors having been allocated key responsibilities for various elements of this action plan. The
implementation of this action plan will be monitored through HQAC and the Trust Board.
g. Review of the Quality & Safety Strategy 2011-2015 and the Governance arrangements
within the Trust
Internal and external audits of MSFT Governance Framework undertaken in 2012 have
demonstrated that the Trust has continued to make improvements in relation to its governance
structures and processes but it needs to embed these consistently throughout the Divisions,
Directorates and down to clinical departments (see page 30).
In order to achieve this, the Chief Executive and Director of Nursing have set up a Project to
ensure that these actions are delivered in 2013-2014. This will be monitored by HQAC and the
Trust Board.
2.3
Statements of Assurance from the Board
During 2012-13 Mid Staffordshire NHS Foundation Trust continued to provide and/or subcontract
57 Clinical NHS services from both Cannock Chase Hospital and Stafford Hospital. (These are
detailed on our web site www.midstaffs.nhs.uk).
The Trust supported a number of reviews of its services during 2012 and 2013.
undertaken by external organisations and include:










These
were
The Care Quality Commission
Cancer Peer Review- Breast and Acute Oncology
Medical and Healthcare Products Regulatory Agency (MHRA)
Health & Safety Executive
NHS Litigation Authority- Acute care and maternity
Clinical Pathology Accreditation
Unannounced visits by the PCT
Local Supervising Authority – midwifery
LINk enters and view visits to the Trust.
Royal College of Paediatrician’s Review
In addition the Trust Board received reports and was assured reviews were undertaken in the
following to help give depth to our understanding of risks and to provide assurance about progress:



Assurance Framework
Governance Framework - Divisional Governance
Quality & Safety Sub-Committee Governance Framework
Mid Staffordshire NHS Foundation Trust |
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Quality Report


April 2012 – March 2013
Information Governance Toolkit
Data Quality Integrated Performance Dashboard
Mid Staffordshire NHS Foundation Trust has reviewed all the data available to them on the quality
of care in 25 of the relevant health services.
The income generated by those services reviewed in 2012-2013 represents 67% of the total
income generated from the total provision of NHS services by the Mid Staffordshire NHS
Foundation Trust for 2012-2013.
2.4 Audits Measuring Participation, Coverage and Review of Clinical
Audits
We consider clinical audit to be a central component of our continual drive to improve the quality
and standards of care delivered. This is being achieved by using audit to look at current practices
and modifying it where necessary”. The audit programme undertaken in 2012/13 covered three
distinct but intertwined areas 1) National Audits 2) Local Audits and 3) NCEPOD:
During 2012/2013, 35 national clinical audits and 4 national confidential enquiries covered relevant
services that MSFT provides.
During 2012/2013 MSFT participated in 91% of national clinical audits and 100% national
confidential enquiries of the national clinical audits and 100% of the national confidential enquiries
which it was eligible to participate in.
The national clinical audits and national confidential enquiries that MSFT was eligible to participate
in during 2012/2013 are as follows: (see table below)
The national clinical audits and national confidential enquiries that MSFT participated in during
2012/2013 are as follows: (see table below)
The national clinical audits and national confidential enquiries that MSFT participated in, and for
which data collection was completed during 2012/2013, are listed alongside the number of cases
submitted to each audit or enquiry as a percentage of the number of registered cases required by
the terms of audit or enquiry.
Title
MSFT Eligible
Part of the National Clinical Audit Patients Outcomes Programme
Perinatal mortality (MBRRACE-UK)
Yes
Neonatal intensive and special care (NNAP)
Yes
Childhood epilepsy (RCPH National Childhood
Yes
Epilepsy Audit)*
Paediatric intensive care (PICANet)*
No
Paediatric cardiac surgery (NICOR Congenital
No
Heart Disease Audit)
Diabetes (RCPH National Paediatric Diabetes
Yes
Audit)*
Diabetes (National Adult Diabetes Audit)*
Yes
Ulcerative colitis & Crohn's disease (UK IBD
Yes
Audit)*
National Review of Asthma Deaths (NRAD)
Yes
Hip, knee and ankle replacements (National
Yes
Joint Registry)*
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| Mid Staffordshire NHS Foundation Trust
MSFT
Participated
Percentage of required
number of cases submitted
Yes
Yes
Yes
100%
100%
100%
-
-
Yes
100%
Yes
Yes
100%
Study ongoing
No
Yes
100%
April 2012 – March 2013
Intra-thoracic transplantation (NHSBT UK
Transplant Registry)
Liver transplantation (NHSBT UK Transplant
Registry)
Coronary angioplasty (NICOR Adult cardiac
interventions audit)*
Carotid interventions (Carotid Intervention
Audit)*
CABG and valvular surgery (Adult cardiac
surgery audit)*
Acute Myocardial Infarction & other ACS
(MINAP)*
Quality Report
No
-
-
No
-
-
No
-
-
No
-
-
No
-
-
Yes
Yes
100%
Heart failure (Heart Failure Audit)*
Yes
Yes
Acute stroke (SINAP)*
Yes
Yes
Cardiac arrhythmia (Cardiac Rhythm
Yes
Yes
Management Audit)*
Renal replacement therapy (Renal Registry)
No
Bowel cancer (National Bowel Cancer Audit
Yes
Yes
Programme)
Head & neck cancer (DAHNO)*
Yes
Yes
Oesophago-gastric cancer (National O-G
Yes
Yes
Cancer Audit)*
Hip fracture (National Hip Fracture
Yes
Yes
Database)*
National Confidential Inquiry into Suicide and
No
Homicide for people with Mental Illness
(NCISH)
National audit of psychological therapies
No
National Audit of Dementia
Yes
Yes
Not Part of the National Clinical Audit Patients Outcomes Programme
Paediatric pneumonia (British Thoracic
Yes
No
Society)
Paediatric asthma (British Thoracic Society)
Yes
Yes
Emergency use of oxygen (British Thoracic
Yes
Yes
Society)
Adult community acquired pneumonia
Yes
Yes
(British Thoracic Society)
Non invasive ventilation -adults (British
Yes
Yes
Thoracic Society)
Cardiac arrest (National Cardiac Arrest Audit)
Yes
Yes from
October 2012
Renal Colic (College of Emergency Medicine)
Yes
Yes
Fractured neck of femur (College of
Yes
Yes
Emergency Medicine)
Paediatric fever (College of Emergency
Yes
Yes
Medicine)
Adult critical care (ICNARC CMPD)
Yes
Yes
Potential donor audit (NHS Blood &
Yes
Yes
Transplant)
Severe trauma (Trauma Audit & Research
No
Network)
Intra-thoracic transplantation (NHSBT UK
No
Transplant Registry)
Blood Sampling and Labelling (National
Yes
Yes
Comparative Audit of Blood Transfusion)
Peripheral vascular surgery (VSGBI Vascular
No
-
100%
100%
100%
100%
100%
100%
-
100%
100%
100%
Study ongoing
100%
100%
100%
100%
100%
100%
100%
100%
-
Mid Staffordshire NHS Foundation Trust |
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Quality Report
April 2012 – March 2013
Surgery Database)
Adult asthma (British Thoracic Society)
Bronchiectasis (British Thoracic Society)
Renal transplantation (NHSBT UK Transplant
Registry)
Renal replacement therapy (Renal Registry)
Prescribing in mental health services (POMH)
Parkinson's disease (National Parkinson's
Audit)
Elective surgery (National PROMs
Programme)
Pulmonary Hypertension
National Audit of Intermediate Care
Yes
Yes
No
Yes
No
-
100%
No
No
Yes
Yes
100%
Yes
Yes
Patient Survey
No
No
-
-
-
The Trust also participated in two other non mandated national audits which are listed below:


Consultant Sign Off Audit (College of Emergency Medicine)
National Audit, Facing the Future: A review of paediatric services
National Audit reports received 2012/2013
The reports of 21 national clinical audits were reviewed by the provider in 2012-2013 and the
MSFT intends to take the following actions to improve the quality of healthcare provided (see table
below).
The National Audit reports are listed in the table below, together with the level of compliance
identified against the standards audited and the key actions identified to address the areas of noncompliance. National audits are discussed at the Speciality Audit and Directorate Governance
meetings and where required remedial action plans agreed. The Trust Clinical Audit meeting,
which meets on a monthly basis monitors progress from a whole Trust viewpoint.
Audit Title
Adult Critical Care (Case Mix
Programme – ICNARC CMP)
Compliance
Level
Partial
National Joint Registry
Good
Renal Colic (College of
Emergency Medicine)
Partial
National Comparative Audit of
Blood Transfusion Programme
Partial
Potential Donor Audit
Partial
National Bowel Cancer Audit
Good
Head and Neck Oncology
(DAHNO)
Partial
16
Actions planned/taken
The Trust continues to maintain high standards of critical care.
Areas of improvement have been identified and planned work will
be undertaken during 2013/2014 to move towards a good level of
compliance.
Overall compliance is good. Actions have been devised and have
been implemented to enhance the consent process and also to
ensure that all documentation is complete.
The report has been considered by the Speciality. An action plan is
currently being developed to address the areas where improvement
is required.
Actions taken in response to national report include the update of
guidelines in connection with named nurses authorised to sign
request forms and in the future rejected samples will be monitored
by the blood bank manager & transfusion quality team.
An action plan has been developed and is in the process of
implemented. A main action implemented is the appointment of a
Specialist Nurse for Organ Donation within the Trust.
The report has been considered by the Speciality. An action plan is
currently being developed to address the areas where improvement
is required.
There has been a comprehensive head and neck locality work plan
agreed and which is in the process of being implemented. Key
actions include the development of a Head & Neck Specialist MDT
covering thyroid and salivary gland and conducting a self
assessment in accordance with the National Peer Review
| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
Lung Cancer (NLCA)
Partial
Oesophago-gastric Cancer
(NAOGC)
Partial
Acute coronary syndrome or
Acute myocardial infarction
(MINAP)
Heart Failure
Partial
National Diabetes Inpatient
Audit
Partial
Paediatric Diabetes
Partial
Fractured neck of femur
Partial
Hip Fracture Database (NHFD)
Good
National Audit of Dementia
Partial
Epilepsy 12 audit (Childhood
epilepsy)
Partial
National intensive and special
care (NNAP)
Partial
Paediatric Asthma
Partial
Paediatric Fever
Partial
Partial
Quality Report
The report has been considered by the Speciality. An action plan is
currently being developed to address the areas where improvement
is required.
The report has been considered by the Speciality. An action plan is
currently being developed to address the areas where improvement
is required.
National audit results only available, this is being considered locally
and the implications addressed via a local action plan.
The report has been considered by the Speciality. An action plan is
currently being developed to address the areas where improvement
is required.
The report has been considered by the Speciality. An action plan is
currently being developed to address the areas where improvement
is required.
The report has been considered by the Speciality. An action plan is
currently being developed to address the areas where improvement
is required.
The report has been considered by the Speciality. An action plan is
currently being developed to address the areas where improvement
is required.
The Trust demonstrates a good level of compliance and has
implemented processes to ensure that all medically fit patients with
a fractured hip are operated upon within 48 hours of admission.
Steering group has been convened to devise an action plan in
response to national report results. Interim action plan agreed. Sign
off and full implementation of plan will take place during 2013/2014
An agreed action plan has been developed to address areas where
improvement was required. A key action was to improve awareness
of guidelines and encourage uptake of ‘Paediatrics Epilepsy
Training’ course and explore the potential of employing a part time
Epilepsy Nurse Specialist
The report has been considered by the Speciality. An action plan is
currently being developed to address the areas where improvement
is required.
An agreed action plan has been developed to address areas where
improvement was required. A key action included to continue to
develop the role of Asthma lead/link Nurse for In-patients and
Children’s Community Nurse to improve discharge and follow-up
process
The report has been considered by the Speciality. An action plan is
currently being developed to address the areas where improvement
is required.
Local Audit Programme
The reports of 37 local clinical audits were reviewed by the provider in 2012-2013 and MSFT
intends to take the following actions to improve the quality of healthcare provided (see table below
for examples of actions):
EXAMPLE: Audit of the management of early and advanced breast cancer (NICE CG80). The audit
focused on the diagnosis and management of the condition and the results indicated that that there was a
high level of compliance with the majority of the criteria. Criteria which was partially met included ‘all
patients should have an agreed written care plan’ and ‘patients should receive chemotherapy within 31
days of surgery’. Actions resulting from the audit included a further audit to establish why the
chemotherapy treatment criteria was not met in all cases (with a view to developing an action plan) and
Mid Staffordshire NHS Foundation Trust |
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Quality Report
April 2012 – March 2013
the development of an standard template to document the agreed written care plan which would be used
by all breast consultants.
EXAMPLE: Audit on Neonatal Transitional Care Project was undertaken to see how we are complying
with Trust local policy guidelines on neonatal transitional care in the department of Paediatrics. The audit
showed that the Trust is partially compliant with only 89% of observations being carried out on babies in
Transitional Care. It was also found that eTTO’s were only completed for 89% of babies at discharge from
Transitional Care. Actions from this audit include encouraging doctors responsible for discharging babies
from the transitional care to complete eTTO’s for all the babies. Every baby being admitted for transitional
care must have regular clinical observations done by the responsible midwife. Local policy will be updated
to reflect this and a re-audit will be carried out once this has been implemented.
EXAMPLE: An audit was carried out in the Haematology department, a partial re-audit of Bedside
Transfusion Practice. It concentrated on the following; recording of vital signs pre-, peri- and posttransfusion and also the correct prescribing of blood.
Addressing the first question as to whether observations were carried out pre-transfusion this was done in
the majority of cases (85.2%) and nineteen had the observations recorded within the recommended hour.
The second question addressed observations peri-transfusion. Twenty-five (92.6%) had observations
recorded after the transfusion started, thus leaving two with no observations recorded.
As part of mandatory training, nursing staff are required to attend blood transfusion safety updates on an
annual basis. These are opportunities for staff to have these timing guidelines consolidated so blood
transfusions can be administered safely and in accordance with evidence based Trust guidelines
EXAMPLE: Stafford Hospital Cardiology ward and Acute Cardiac Unit currently implement ‘Patient
Summary’ sheets, to assimilate information concerning the patient’s admission details, demographics and
investigations into one, easily-accessible place. Of the 50 patients looked at, the date was documented in
80% of the cases, the consultant was recorded in 76% of cases and the presenting complaint was
documented in 84% of cases. The audit shows that there are an insufficient number of Problem Sheets
being completed. This may be due to a number of factors such as patients discharged on the same day
and insufficient time to complete the form, no consistency in filling the investigation, members of the team
failing to appreciate the value of completing a Problem Sheet, etc. We believe that we can overcome
some of these factors by highlighting our findings to the doctors on the Cardiology ward by Email, or by
using posters and making sure the doctors receive a written introduction.
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| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
Quality Report
The audits completed in 2012/2013 are included in the following table:
Specialty
Audit topic
Anaesthetics/Theatres
Breast Screening
Breast Surgery
Cardiology
Cardiology
Dermatology
Dermatology
Dermatology
Dermatology
Dermatology
Dermatology
ENT
Gastro/Endo
Midwifery
Midwifery
Midwifery
Midwifery
Obstetrics
Obstetrics
Obstetrics
Paediatrics
Paediatrics
Paediatrics
Paediatrics
Paediatrics
Pathology
Radiology
Trauma & Orthopaedics
Trauma & Orthopaedics
Trauma & Orthopaedics
Trauma & Orthopaedics
Trauma & Orthopaedics
Trauma & Orthopaedics
Trauma & Orthopaedics
Trauma & Orthopaedics
Trauma & Orthopaedics
Urology
Post obstetric anaesthetic follow-up
Compliance of NICE clinical guidelines (breast
cancer diagnosis and treatment)
Surgical Cavity Random Biopsy
Diagnostic Angiography Audit
Pacemaker Implant Audit
Melanoma Audit
Review of Merkel Cell Carcinoma presenting to MSGH
Re-audit of Wound infection following Dermatological
Surgery
Audit of Dermatology Activity: secondary and
community care services
Re-audit of Use and Monitoring of Biological
Therapies in Psoriatic patients
Dermatology record keeping
Clinical indication for MRI for people with acoustic
neuroma according to NICE
Thiopurine use in patients with inflammatory bowel
disease
Management of baby slow to initiate and establish
breast feeding
Weighing the baby
Kiwi ventouse audit
Audit of antenatal screening
Audit on review of standards of operative vaginal
delivery at Stafford Hospital
Management of patients post op in theatre recovery
An audit into miscarriage management
Audit on Neonatal Transitional Care
Audit of fluid resuscitation and insulin administration
in diabetic keto-acidotic children
Management of suspected pertussis (whooping
cough) in paediatric patients (HPA guidelines)
Audit of Enteral Feeding in Children
Audit of Azathioprine use in Children with IBD (re-audit)
Audit of cytology and radiology in FNA thyroid
Portable chest imaging quality and diagnostic value
audit
The radiological and clinical outcome of the
management of ACJ disruption (with or without
fracture) with Sugilig reconstruction
Identification and treatment of osteoporosis
within an orthopaedic setting
Secondary prevention of osteoporosis after
distal radius fragility fracture
Appropriateness of referrals to specialist knee clinic
Pressure Ulcers in Trauma Patients
Assessment of post-operative arthroplasty
radiological evaluation
Re-audit of Group and Save's taken on NOF#
patients in September 2012
Audit of Neck of Femur Consenting
Presentation relating to standards of hip fracture care
Audit of Urology Referrals
Mid Staffordshire NHS Foundation Trust |
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Quality Report
April 2012 – March 2013
We have also participated in a number of National Confidential Enquiry into Patient Outcome and
Death (NCEPD) audits and have considered a number of NCEPOD reports and reviewed our care
pathways in line with the recommendations. This work has been lead by the hospitals NCEPOD
ambassador.
NCEPOD Reports 2012/13
Report Title
Too Lean a Service: A review of the care
of patients who underwent bariatric
surgery
Time to Intervene? A review of patients
who
underwent
cardiopulmonary
resuscitation as a result of an in hospital
cardio-respiratory arrest
NCEPOD Studies in Progress 2012/13
Report Title
Considered
by Trust
Yes
Yes
Alcohol Related Liver Disease
Trust
Involvement
Yes
Subarachnoid Haemorrhage
Yes
Tracheostomy Study
Yes
2.5
Comments
The Trust does not perform bariatric surgery
therefore a gap analysis was not required to be
undertaken.
The Trust had completed a gap analysis and is
partially compliant with the recommendations.
A detailed action plan has been developed and
is awaiting formal sign off in May 2013.
Comments
The Trust has submitted an organisational
questionnaire and clinician questionnaires. The
report is expected to be published in April 2013
The Trust has submitted an organisational
questionnaire. The report is expected to be
published in September 2013
The Trust has submitted an organisational
questionnaire and as the study is in the data
collection stage continues to complete the
clinician questionnaires. The report is expected
to be published in June 2014.
Participation in Clinical Research
Commitment to research as a driver for improving the quality of care and patient
experience
We take the view that 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.
By our clinical staff staying abreast of the latest possible treatment possibilities and active
participation in research leads to successful patient outcomes.
It is therefore pleasing to report that 433 patients receiving NHS services provided or subcontracted care by Mid Staffordshire NHS Foundation Trust in 2012/13 were recruited to
participate in research approved by a research ethics committee.
Mid Staffordshire NHS Foundation Trust was involved in conducting 129 clinical research studies
in:







20
Oncology
Haematology
Respiratory medicine
Cardio-vascular medicine
Acute Medicine
Gastroenterology
Medicines for Children
| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013





Quality Report
Reproductive Health
Musculoskeletal
Dermatology
Diabetes and Endocrinology
Orthopaedics
The improvement in patient health outcomes at the Trust demonstrates that a commitment to
clinical research leads to better treatments for patients. There was 68 clinical staff participating in
research approved by a research ethics committee at Mid Staffordshire NHS Foundation Trust
during 2011/12. These staff participated in research covering 11 of medical specialties.
Although no publications have directly resulted from our involvement in National Institute for Health
Research (NIHR), our engagement with clinical research demonstrates the Trusts commitment to
testing and offering the latest medical treatments and techniques.
2.6
Quality Indicators
Commissioning for Quality and Innovation (CQUIN)
a. CQUIN for 2012-2013 and achievements against these
A proportion of the Trust’s income for 2012-2013 was conditional on achieving the quality and
innovation goals agreed through the Commissioning for Quality and Innovation payment framework
(CQUIN), with a value equivalent to 2.5% of the contract.
We agreed 7 goals with South Staffordshire Primary Care Trust with a monetary value of
£3,296,757 if all aspects of these quality improvement and innovation goals were achieved in
2012-2013. We achieved £2,285,752 which was 69.3% of the income.
In 2011-2012 the monetary value for the CQUIN was £1,832,247, the Trust achieved £1,616,957
which was 88% of the potential income.
The CQUINs for 2012-2013 and the achievements against these are outlined below:
CQUIN
Description
Goal 1
Venous thromboembolism (VTE)
Goal 2
Patient Experience
Percentage of all adult inpatients who have had a VTE risk
assessment on admission to hospital using the clinical
criteria of the national tool
a) National Survey
The indicator is a composite calculated
From 5 survey questions:
1.
Involvement in decisions about
treatment and care
2. Hospital Staff being available to talk about
worries/concerns
3.
Privacy when discussing condition/
treatment
4.
Being informed about side effects of
medication
5.
Being informed who to contact if
worried about condition after leaving
hospital
b) Regional Survey
The Trust was required to establish a baseline and Net
Promoter Score for 10% of inpatients and achieve a 10
point improvement in Net Promoter Score
Potential
Income
£164,838
Income
Achieved
£164,838
100
£164,838
£164,838
100
£197,805
£197,805
100
Mid Staffordshire NHS Foundation Trust |
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21
Quality Report
Goal 3
Safe Care
Goal 4
Dementia
Goal 5
End of Life Care
Goal 6
Medication Errors
Goal 7
Discharge
April 2012 – March 2013
The CQUIN requires monthly surveying of all appropriate
patients (as defined in the Safety Thermometer guidance)
to collect data and improve the safe care of patients on 4
outcomes
1. Pressure ulcers
2. Falls
3. Urinary Tract infections
4. VTE Prophylaxis
1. Percentage of all patients aged 75 and over that have
been screened following emergency admission to
hospital using the dementia case finding question.
2. Percentage of all patients aged 75 and over who have
scored positive on the case finding question, who
have had a dementia assessment using the 6 CIT
assessment tool.
3. Percentage of all patients aged 75 and over who have
had a diagnostic assessment (in whom the outcome
was either positive or inconclusive) who have been
referred to the Dementia Team.
Includes the following:
1. Implementation of the AMBER Care Bundle
2. Training and Development
3. LCP implementation measures
Improvement in medicines management
1. Completion of prescription charts
2. Reduction in omitted doses without a medically
justified reason
3. Reduction in eTTO errors
Improvement in transfers between Trusts in the Cluster.
£1,483,541
£1164,854
78.52
£560,449
£263,741
47.06
£329,676
£98,903
30
£329,676
£164,838
50
£65,935
£65,935
100
Explanation of variance in Performance against 2012-2013- CQUINs
Dementia
The Dementia CQUIN was implemented in Q3 of 2012. The main challenge has been embedding
the case finding question and assessment into all our clinical areas and ensuring that these are
accurately recorded. Although performance against the measures included in this CQUIN have
steadily increased in Q4 we did not achieve the 90% target. Improving our performance in relation
to the screening and assessment of our patients for Dementia remains a key priority for 20132014. We are appointing a Dementia Project Nurse in 2013 to support this process.
End of Life Care
The End of Life Care (EOLC) CQUIN was implemented in Q3 of 2012. It had been agreed that
AMBER would be implemented on 3 wards in total over Q3 and Q4 (one ward every 2 months is
recommended for timescale for roll out of AMBER). Additional staff were recruited to support the
palliative care team in the roll out of the AMBER Care Bundle and the EOLC training. The delay in
these staff starting meant that the AMBER roll did not start until Q4. It was fully implemented on
one ward and partially on the other two areas identified. The EOLC training programme was fully
delivered. The roll out of the AMBER Care Bundle on 8 other areas remains a CQUIN for 20132014. The Trust will also roll out a programme of “Sage and Thyme” communication training as
part of this CQUIN in 2013-2014.
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| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
Quality Report
Medication Errors (see page 10)
b. The CQUIN Agreed for 2013-2014
A proportion of the Trust’s income for 2013-2014 has again been agreed through the
Commissioning for Quality and Innovation payment framework (CQUIN), with the same value
equivalent to 2.5% of the contract.
The Trust agreed 8 goals with the Commissioners a monetary value of £3,244,941 if all aspects of
these quality improvement and innovation goals are achieved in 2013-2014. The CQUIN for 20132014 are outlined over page:
CQUIN
Description
Goal 1
Friends and Family
Test
Continue to improve the patient experience through:
1a. Friends and Family Test phased expansion to
inc. maternity and the Accident and Emergency
Department
1b. Increased response rate (15%) for Friends and Family Test
1c. Friends and Family Test: improved
performance on staff test from the baseline of
58%
2a. Monthly data collection of the NHS Safety Thermometer for the following
elements of care: pressure ulcers, falls, urinary tract infections for patients
with a catheter
2b. Reduction in the prevalence of pressure ulcers
2c. A reduction in the incidence of pressure ulcers
(hospital acquired)
To incentivise the identification of patients with Dementia and other causes of
cognitive impairment alongside their other medical conditions.
3a.
Percentage of all patients aged 75 and over who have been screened
following emergency admission to hospital using the dementia case
finding question.
Percentage of all patients aged 75 and over who have scored positive on
the case finding question, who have had a dementia assessment using
the 6 CIT assessment tool
Percentage of all patients aged 75 and over who have had a diagnostic
assessment (in whom the outcome was either positive or inconclusive)
who have been referred to the Dementia Team.
3b. Clinical Leadership and Planned Training
Programme.
3c. Supporting carers of people with Dementia
4a. Percentage of all adult inpatients who have had a VTE risk assessment
undertaken within 12 hours of admission to hospital using the clinical criteria
of the national tool
4b.The number of Root Cause Analysis (RCA)
Investigations carried out on hospital
associated VTE
5a. Patients admitted with a COPD exacerbation,
who have a length of stay of over 72 hours,
should be discharged with a completed COPD
care bundle to improve their understanding of
the disease, improve self management and
reduce the likelihood of further admission.
5b. This admission care bundle describes high
impact actions to ensure the best clinical
outcome for patients admitted with an acute
exacerbation of COPD.
Goal 2
NHS Safety
Thermometer
Goal 3
Dementia
Goal 4
Venous thromboembolism (VTE)
Goal 5
COPD care bundle
Mid Staffordshire NHS Foundation Trust |
Potential
Income
£324,494
£486,742
£811,235
£324,494
£324,494
23
Quality Report
Goal 6
Enhanced Recovery
Programme
Goal 7
Implementation of
the Amber Care
Bundle
Goal 8
Nursing Metrics.
2.7
April 2012 – March 2013
To reduce the length of stay for patients receiving hip and knee replacements
through the implementation of the enhanced recovery scheme. The adoption of
enhanced recovery is proven to reduce length of stay, enhance the patient
experience and improve clinical outcomes.
Amber Care Bundle (AMBER) – makes it easier for nurses and consultants to have
future planning conversations with patients whose recovery is uncertain thereby
enhancing the patient experience and care of patients with palliative care needs. It
allows the patient to be involved in decisions about their care and supports the
work already in progress with the hospital related to improving the care of
patients at the end of life, and better discharge planning.
7a. Implementation of the AMBER Care Bundle for
patients in whom recovery is uncertain
7b. Roll out of the Sage and Thyme training
programme
Urinary incontinence (UI) is a common condition that may affect women and men
of all ages, with a wide range of severity and nature. Although rarely lifethreatening, it may seriously influence the physical, psychological and social
wellbeing of affected individuals. The impact on the families and carers of women
and men with UI may be profound, and the resource implications for the health
service considerable.
8a. Implementation of a Continence assessment
for all adult patients
8b.Implementation of a continence care plan for
those patients assessed as having continence
needs
8c. The number of patients assessed as having
Continence issues are then referred to
Specialist Continence Services.
8d. Improvement in continence audit results on
adult wards
£486,741
£162,247
£324,494
What Others Say About Mid Staffordshire NHS Foundation Trust
We have said that we wanted to deliver care to our patients which meets national standards and
through external inspection reassures our patients that the care they will receive will be amongst
the best.
Care Quality Commission (CQC) Registration
The Care Quality Commission is an independent regulator of all health & social care services in
England. The Commission checks all hospitals in England to ensure they are meeting national
standards and they share their findings with the public.
What are the national standards?
The national standards cover all aspects of care including:




Treating people with dignity and respect
Making sure food and drink meets people’s needs
Making sure that the environment is clean and safe
Managing and staffing services
Mid Staffordshire Foundation Trust (MSFT) is required to register with the Care Quality
Commission and is currently registered without compliance conditions. MSFT has the following
conditions on registration: the provider conditions that the regulated activities MSFT has registered
for may only be undertaken at Stafford Hospital and Cannock Chase Hospital.
The Care Quality Commission has not taken enforcement action against MSFT during 2012-2013.
All scheduled inspections are unannounced and focus on a minimum of 5 national standards.
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| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
Quality Report
MSFT has participated in special reviews or investigations by the Care Quality Commission
relating to the following areas during 2012-2013 (see table below). The Care Quality Commission
judged that the Trust was fully compliant with all standards assessed. The inspectors did not
request the Trust to take any actions in respect of outcomes reviewed during these inspections.
The Trust underwent three unannounced Care Quality Commission inspections during 2012/13, in
March 2013, February 2013 and June 2012 (see table below).
Date
March 2013
February 2013
June 2012
Trust Site
Cannock Chase
Hospital
Stafford
Hospital
Stafford
Hospital
Type of Inspection
Unannounced inspection of Core Essential
Standards:
Outcome 4 – Care and Welfare of People who
use services
Outcome 14 – Supporting Staff
Unannounced inspection of Core Essential
Standards:
Outcome 1 - Respecting and involving people
who use services
Outcome 4 – Care and Welfare of people who
use services
Outcome 7 – Safeguarding people who use
services from abuse
Outcome 14 - Supporting Staff
Outcome 17 - Complaints
Unannounced inspection of Core Essential
Standards:
Outcome 2– Consent to care and treatment
Outcome 4 – Care and welfare of people who
use services
Outcome 7 – Safeguarding people who use
services from abuse
Outcome 9 – Management of medicines
Outcome 13 – Staffing
Outcome 14 - Supporting Staff
Outcome 16 – Assessing and monitoring the
quality of service provision
Outcome 17 - Complaints
Outcome
Standard met
Standard met
Standard met
Standard met
Standard met
Standard met
Standard met
Standard met
Standard met
Standard met
Standard met
Standard met
Standard met
Standard met
Standard met
A selection of the comments made in those reports is given below:
One patient told us he had been told about and agreed to his treatment and had been kept
informed about his care. Another patient said, "They nearly always tell you what they are going to
do".
One patient had only been admitted the previous day from A & E but said that the care they had
received had been "brilliant". They said that everything had been explained and that they had
agreed to the treatments prescribed.
We saw evidence of one-to-one support being given to vulnerable individuals on the medical ward
and saw staff giving reassurance in a gentle manner. On one ward we observed a health care
Mid Staffordshire NHS Foundation Trust |
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Quality Report
April 2012 – March 2013
assistant talking to a confused patient using 'distraction skills' to reduce the distress and pacify the
individual. We saw staff assisting patients around the ward.
We spoke to an occupational therapist who described the positive working relationships between
the different staff groups in the hospital and the benefits this brought to patients. Dieticians, nurses,
occupational therapists, physiotherapists, social workers and discharge co-ordinators met regularly
to ensure the smooth transition of people back into their communities wherever possible. Joined-up
care in the hospital and good links with service providers in the community meant that people felt
safe to move on to the next stage of their care.
People we spoke told us that they generally knew how to make a complaint but felt that they could
talk to the staff if they had any problems or questions. One patient when asked about making a
complaint told us "Complain, why would I do that? They are brilliant here, best hospital around."
The Care Quality Commission has, since 2010, published a monthly risk assessment of all
healthcare providers, known as the Quality and Risk Profile. The Care Quality Commission
populates these indexes using information they receive from a number of sources including
statutory agencies and comments received from the general public. A summary of the information
contained within these monthly reports is reviewed at the Trust’s Healthcare Quality Assurance
Committee meetings and any action taken if any necessary over and above those already planned.
2.8
Clinical Data
We consider that central to our intension to improve the quality of care we give to patients is the
need to have robust and accurate clinical data. Clinicians need to have confidence in the
information they may require to make decisions on future care of patients and service
configuration. The Trust seeks assurances from a number of sources that the quality of data being
submitted by the hospital is accurate and robust.
NHS Number and General Medical Practice Code
We submitted records during 2012/13 to Secondary Uses Service for inclusion in the Hospital
Episode Statistics.
The percentage of records in the published data which include the patient’s valid NHS number
was:
99.54% for Admitted Patient Care
99.75% for Outpatient Care
96.51% for Accident & Emergency Care
The percentage of records in the published data which included the patients valid general medical
practice code was:
99.46% for Admitted Patient Care
99.16% for Outpatient Care
96.89% for Accident & Emergency Care
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| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
Quality Report
Payment by Results (PbR Assurance 2012/13)
MSFT was subject to the Payment by Results clinical coding audit during the reporting period by
the Audit Commission and the error rates reported in the latest published audit for this period for
diagnoses and treatment coding (or clinical coding) were:.
For 2012/13 admitted patient care data from - Orthopaedic non trauma procedures from Quarter 2
of 2012/13 was chosen for review. This area was selected as it showed an increase in activity in
quarter 1 compared to the previous year, and the level of activity was higher than expected.
PbR Audit: 2012/2013
Total Audited: 200 FCE’s – Quarter 2 of 2012/13
Areas sampled:
200 FCE’s Non Orthopaedic Trauma Procedures
Percentage of spells changing Payment & HRG:
6%
PbR Audit Comparison
APC Audit Results 2007/08 -2009/10 &
2011/12 & 2012/13
Percentage of HRGs derived incorrectly
Percentage of Primary Procedures recorded
incorrectly
Percentage
of
Secondary
Procedures
recorded incorrectly
Percentage of Primary Diagnosis recorded
incorrectly
Percentage of Secondary Diagnosis recorded
incorrectly
HRG
PP
2007/
08
7.0
17.0
2008/
09
5.0
10.4
2009/
10
16.5
16.2
2011/
12
12.5
12.9
2012/
13
6.0
8.0
SP
16.0
9.5
11.1
3.9
15.4
PD
28.0
20.0
21.2
13.0
9.0
SD
40.0
16.4
12.3
8.8
14.0
Summary of Findings 2012/2013
The Performance of the Trust, places the Trust in a better than average compared with last year’s
national performance, however not in the top 25%.
The majority of the spell HRG changes affecting price were due to coder error. This included not
extracting the information correctly. Also not coding post operative complication such as post
anaemia. The financial value of the sample Audit was £466,038. The net impact of errors shows
that the Trust undercharged the commissioners by £7,850
A number of training issue were identified which affected the audit, especially around extraction,
identification and indexing of diagnoses and procedures, some of the errors were attributed to new
staff. Patient case notes, electronic discharge summaries combined with the various clinical
systems provided good coding source documents. It was noted that patient case notes were poorly
filed. In cases where notes differed from the discharge summary this resulted in coding information
errors 22.7% some of which effected payment.
Coding Accuracy – T&O Non Trauma Operations
Primary Diagnosis: 92%
Secondary Diagnosis: 85%
Primary Procedure: 91%
Secondary Procedure: 86%
Mid Staffordshire NHS Foundation Trust |
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Quality Report
April 2012 – March 2013
The results should not be extrapolated further than the actual sample audited. The following
service was reviewed: Orthopaedic non trauma procedures.
Ensuring that the data available is accurate and timely is crucial in helping us make improvements
at all levels within the organisation. This is monitored via our Data Quality Group whose purpose is
to assure the Trust that the data it uses both electronic and manual is robust and accurate and to
take action where required.
The Trust’s operational Divisions have responsibility for data quality in their areas.
MSFT will be taking the following actions to improve the data quality:




Review the Data Quality Policy regularly via the Data Quality Group
Ensure Level 2 compliance with the Information Governance Toolkit is achieved
Continue with the internal audit programme undertaken by the Trust’s Accredited Auditor
Ensure the PbR Data Assurance Programme Action Plan developed following the 20122013 PbR audit is fully implemented.
IG Toolkit Submission
The Information Governance Toolkit is a self assessment that gives assurance to our regulators
and commissioners that the Trust complies with standards and legislation that includes data
protection and confidentiality; information security; information quality; health/care records
management; corporate information.
We said that we would aim to be compliant at Level 2 across all 44 requirements by the end of
2012/13. The Trust achieved the following rating:
Level 1 = 3
Level 2 = 23
Level 3 = 18
MSFT Information Governance Assessment Report overall score for 2012-2013 was 78% and was
graded red from the IGT Grading Scheme.
MSFT was graded red as the Trust was assessed as non compliant with 3 requirements out of 44
as we did not achieve the target Level 2. These are outlined below:

10-112 - 95% of staff to receive annual Information Governance refresher training
To provide more flexibility in the way staff can access training an E learning package was
introduced in February, for all mandatory training modules. Unfortunately the uptake has
been slow. As at 27th March the percentage of staff that had completed annual IG training
was 88%.
The following two standards relate to the issuing and ongoing management of staff security access
cards for use with the hospitals IT systems. Whilst the Trust does have a system of issuing staff
with smartcards, the linkage with the staff computerised system held in the human resources
department were not as robust as the Trust would expect.

10-303 – The organisation has obligations as a Registration Authority.
These issues are being addressed by the Human Resources Department and action plans
have been agreed which will ensure full compliance with the standards.

10- 304 – Smartcards processes and monitoring are in place.
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Quality Report
These issues are being addressed by the Human Resources Department and action plans
have been agreed which will ensure full compliance with the standards.
Information Commissioners Office Complaint
A complaint was made in October 2012 regarding information the Trust withheld from the BBC
following a Freedom of Information request.
In the particular circumstances of this case the Commissioner took the decision to proactively
consider Section 41 (information provided in confidence) of the Freedom of Information Act in
relation to this request and he concluded that the vast majority of the withheld information is
exempt from disclosure and upheld the Trusts decision.
Information Asset Owners/Administrators
A number of senior managers have been designated as Information Asset Owners supported by
administrators within their departments, which will provide a structure to progress the management
of corporate information.
One Staffordshire Data Sharing Protocol
The Trust has now signed up the ‘One Staffordshire Information Sharing Protocol’. The protocol
has been produced by a working group made up of representatives from various public bodies
across Staffordshire and reflects the current information sharing climate, legislative requirements
and best practice. It outlines the purposes for sharing information, the powers that organisations
have to share information, the role of partners and what can be expected from them and the
process for sharing with template sharing agreements available in the appendices.
2.9
National Health Service Litigation Authority (NHSLA)
The NHSLA handles negligence claims and works to improve risk management practices in the
NHS. A key function for the NHSLA is to contribute to the incentives for reducing the number of
negligent or preventable incidents within the NHS. They aim to achieve this through an extensive
risk management programme. The core of their risk management programme is provided by a
range of NHSLA standards and assessments.
All the NHSLA Standards are divided into three “levels” one, two and three. NHS organisations
which achieve success at level one in the relevant standards receive a 10% discount on their
contributions to the Clinical Negligence Scheme for Trusts (CNST) and the Risk Pooling Scheme
for Trusts, with discounts of 20% and 30% available to those passing the higher levels. The CNST
Maternity Standards are also divided into three levels and organisations successful at assessment
receive a discount of 10%, 20% or 30% from the maternity portion of their CNST contribution. If a
Trust fails to achieve the minimum standards the NHSLA will award the Trust a zero rating, in such
circumstances a re-assessment must take place within 6 months.
2012 /13 Assessments Undertaken
The NHSLA undertook two assessments of the Trust against the general and maternity standards
during the last year. The assessment of general services took place in September 2012 and the
maternity services in February 2013. The Trust was judged to be compliant for both sets of risk
standards at Level 1.
General Assessment:
The general service (acute) was assessed against five standards each containing ten criteria
giving a total of 50 criteria. In order to gain compliance at Level 1 the Trust was required to pass at
least 40 of these criteria, with a minimum of seven criteria being passed in each individual
standard. The Trust scored as follows:
Mid Staffordshire NHS Foundation Trust |
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Quality Report
Governance
Learning from Experience
Competent & Capable Workforce
Safe Environment
Acute Services
OVERALL COMPLIANCE
April 2012 – March 2013
10/10
10/10
10/10
7/10
8/10
45/50
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Maternity Assessment
The maternity service was assessed against five standards each containing ten criteria giving a
total of 50 criteria. In order to gain compliance at Level 1 the Trust was required to pass at least 40
of these criteria, with a minimum of seven criteria being passed in each individual standard. The
Trust scored as follows:
Organisation
Clinical Care
High Risk Conditions
Communication
Postnatal & Newborn Care
OVERALL COMPLIANCE
10/10
10/10
10/10
10/10
10/10
50/50
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
2.10 Human Tissue Authority (HTA) Inspection Report
The Human Tissue Authority aim to maintain confidence by ensuring that human tissue is used
safely and ethically, and with proper consent. They regulate organisations that remove, store and
use tissue for research, medical treatment, post-mortem examination, teaching and display in
public. The HTA also give approval for organ and bone marrow donations from living people.
Following a routine inspection of the Trust, the HTA found the Designated Individual, the Licence
Holder, the premises and the practices to be suitable in accordance with the requirements of the
legislation. This followed a non-routine inspection of Stafford Hospital mortuary following a serious
untoward incident. The corrective and preventative actions that were agreed with the HTA following
the establishment’s internal investigation were found to have been fully implemented and the HTA
was satisfied that these actions mitigate the risk of a similar incident happening again.
The Trust was found to have met all HTA standards. Whilst no shortfalls against standards were
found, to aid continuous improvement, the HTA gave advice to the Designated Individual on
several areas where improvements could be made, some of which was similar to the advice
provided following the previous inspection.
2.11 Quality Governance Framework
As a Foundation Trust, the hospital is required to be compliant with the Quality Governance
Framework, a system of working used by Monitor – the independent regulator of Foundation Trust.
This sets out a number of standards with four domains, the domains being a) Strategy b)
Capabilities c) Structure & Process d) Measurement. Following significant improvements that the
Trust made in governance structures and processes during 2011-12 a review was completed by
the Trust’s internal auditors in April 2012. This concluded that the Trust’s self assessment
previously undertaken was supported by sufficient evidence to confirm the overall score of 2.5
against a maximum Monitor target of 4.0. The report identified that the Trust still had some further
work to do and that this was represented with 5 areas remaining at an amber/green status (each
attracting a score of 0.5) with the other 5 areas being compliant and therefore green and a score of
0.0.
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Quality Report
During 2012/13 at the request of the Trust a further review was undertaken by Price Waterhouse
Cooper in to two specific areas of “is appropriate quality information being analysed and
challenged?” and “is quality information being used effectively?” In their report of October 2012 it
was acknowledged that the Trust had continued to make improvements in these areas and had
plans to continue to refine and embed these improvements and the status at that point in time was
amber/green.
The main issue arising from the audits referred to above was one of the Trust needing to embed
governance structures and processes consistently throughout directorates and down to clinical
departments. Through working with Clinical Directors and General Managers the Trust believes
that good progress has been made in achieving this; this view being supported to an extent by a
general review of directorate governance arrangements undertaken by the Trust’s internal auditors
recently concluded. In order for the Trust to receive assurance through a focused audit specifically
on the Quality Governance Framework requirements, a scope has been agreed within the Trust
and is currently with Monitor for consideration before providing to an externally based auditor to
agree details and timescales for completion of the audit. The Trust expects the outcome of the
audit to confirm that the Trust has continued to make improvements in embedding the governance
structures and processes and continued further improvements will be made during 2013/14.
2.12 Safeguarding – Adults and Children
We continue to contribute and take an active participation in the Multi-Agency Safeguarding Hub
(MASH). This group receives all safeguarding and children protection enquiries and referrals. The
MASH is staffed with specifically trained professionals from a range of agencies including police,
probation, fire, ambulance, health, education and social care. These professionals triage the
referrals and share information to ensure early identification of potential significant harm, and
trigger interventions by the relevant professionals to prevent further harm.
The Trust Board is made aware of Serious Incidents where staff have raised concerns about the
performance of colleagues. The Director of Quality and Patient Experience represents the Trust on
both the Paediatric Safeguarding Board and the Stoke-on-Trent and Staffordshire Adult
Safeguarding Partnership Board (SSCB). Operational sub committees of both boards are also well
represented by staff from the Trust. Trust referral rates remain stable for both paediatric and adult
referrals.
Safeguarding Training
Safeguarding Children Advanced Training Compliance by Staff Group at end of March 2013:
Staff Group
Add Prof Scientific and Technical
Additional Clinical Services
Administrative and Clerical
Allied Health Professionals
Healthcare Scientists
Medical and Dental
Nursing and Midwifery Registered
Grand Total
Non Registered
21
79
21
42
2
123
109
401
Registered
12
48
19
58
7
16
134
294
Total
33
127
40
100
9
139
243
695
Percentage
36.36%
37.80%
47.50%
58.00%
77.78%
11.51%
55.14%
42.30%
Staff throughout the Trust has been allocated to the appropriate levels for children’s safeguarding
training. Extra resources have been identified to deliver training and liaison. Latest figures for basic
awareness training are 90.39%, Staffordshire Safeguarding Children Board (SSCB) target is 80%.
Figures for advanced level training are 42.30% for all staff groups.
Mid Staffordshire NHS Foundation Trust |
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Quality Report
April 2012 – March 2013
Safeguarding Adults Advanced training compliance by staff group at end of March 2013:
Staff Group
Add Prof Scientific and Technicians
Additional Clinical Services
Administrative and Clerical
Allied Health Professionals
Estates and Ancillary
Healthcare Scientists
Medical and Dental
Nursing and Midwifery Registered
Grand Total
Non Registered
11
369
130
42
37
20
257
430
1296
Registered
4
179
39
115
23
10
27
352
749
Total
15
548
169
157
60
30
284
782
2045
Percentage
26.67%
32.66%
23.08%
73.25%
38.33%
33.33%
9.51%
45.01%
36.63%
Latest figures for basic awareness training are 90.39% and 36.63% for advanced training.
All Divisions now address adult safeguarding compliance at their monthly governance meetings as
a performance issue to raise this on the Trust agenda. An E-learning Adult Advanced
Safeguarding package continues to provide an alternative method for medical staff to address the
current low attendance rate.
2.13 Equality and Diversity Update
The Equality and Diversity System (EDS), chaired by Sir David Nicholson, was launched in
November 2011. It is a tool made up of four goals and eighteen outcomes designed to imbed
equality into the NHS with the intention to support NHS organisations to improve health outcomes
for patients, carers, communities and staff who fall under one or more of the nine protected
characteristics: age, sex, sexual orientation, gender reassignment, race, religion & belief, disability,
marriage, pregnancy and maternity.
We now have seventeen Equality and Diversity Advocates who have expressed an interest in
taking the EDS strategy forward supported by the Head of Patient Experience and the Deputy
Head of Organisational Development and Training. One of the main challenges is that this agenda
is very resource intensive therefore commitment has been received from the manager of each
advocate for the equivalent of one day a month from their substantive posts to concentrate on
research, engagement and implementation of initiatives.
The Impact Assessment Policy has been revised to include all nine protected characteristics and to
ensure it is more user friendly for staff when writing policies and considering service development.
Improved communication is promoted in a variety of ways including patient passports,
communication books, hearing loops and “Ping Pong” nurse call alarms for patients who are
unable to use the traditional nurse call bells. Direct Enquiries have assessed both hospital sites for
disability access, made recommendations and filmed the Trust so that the public can access the
site via the internet and have a visual picture of where they need to go once they arrive at the
hospital. This is particularly beneficial to the disabled and those patients with learning disability or
autism who find it traumatic when they need to visit an unfamiliar environment.
2.14 Hospital Readmissions Rate Data
We use information available to review the numbers of patients readmitted to hospitals within 28
days of being discharged and compare our performance nationally. The hospital has a
readmissions group, lead by a senior clinician which works to ensure we deliver the best possible
care pathways. The group undertake regular checks.
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April 2012 – March 2013
Quality Report
Our performance for the financial year 2012/2013 is as follows;
Admissions*
28 day Readmissions
28 day Readmission rate %
18,934
2070
10.93%
2.15 Performance against the Nationally Mandated set of Quality
Indicators
For 2012-2103 all Trusts are required to report against a core set of indicators for at least the last
two reporting periods. The data source for all these indicators is the Health and Social Care
Information Centre (HSCIC) which has only published data for part of the 2012-2013 reporting
period. The Trust’s performance for the applicable quality indicators is shown in Appendix A on
page 53.
3.
Other Information
This section provides an overview of the quality of care provided in 2012-2013 for a selection of
indicators relating to patient safety, clinical effectiveness and patient experience.
The Board of Directors chose to include several of the quality of care indicators which were
included in the 2011-2012 Quality Account, this enables our patients and public to understand the
Trust performance over time and the improvements that have been achieved. National
performance data, where applicable, is included. These indicators are: Reducing Hospital Acquired
Infections Serious Incidents, Falls, Nursing Assurance, Reducing our Hospital Standardised
Mortality Ratio (HMSR), National Inpatient Survey and complaints. Other indicators relating to
patient experience and clinical effectiveness have also been included as they have been key
quality indicators for the Trust in 2012-2013.
3.1
Patient Safety
a. Reducing Hospital Associated Infections – Clostridium Difficile (C.Diff) and MRSA
Reducing avoidable hospital associated infection has continued to remain a key area of our work
throughout 2012-2013.
We are very proud that none of our patients acquired a MRSA bloodstream infection in 2012-13
and we were therefore better than the target set of no more than 1 case. In 2011-12 we had 2
cases of MRSA blood stream infections. The target for 2013-2014 is zero.
We were set a target of no more than 24 cases for Clostridium Difficile. 25 cases were identified
which means we were over our target by one patient, although this was still a reduction of 1 case
from the previous year. It is important to highlight that Mid Staffs has seen a year on year reduction
in cases of C.Diff. This is depicted in the figure below:
Mid Staffordshire NHS Foundation Trust |
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Quality Report
April 2012 – March 2013
The Health Protection Agency (HPA) data set out C.Diff cases per 100,000 bed days which allows
comparison between Trusts. Figure 2 outlines data collected by the HPA between October 2011
and September 2012. MSFT is highlighted in yellow and has the second lowest rate per 100,000
bed days of C.Diff during this period compared with our neighbouring Trusts.
Baseline rate per 100,000 bed days Comparsion
October 2011 - September 2012
35
30
Baseline Rate
25
20
Mid Staffordshire
A
B
C
D
E
F
G
H
I
J
15
10
5
J
I
H
G
F
E
D
C
B
A
Mid Staffordshire
0
Hospital
(It must be noted that during October 2012 the Trust reported 9 cases of Mid Staffs attributed
C.Diff. This is not captured in the data).
The Infection Control Team have developed a C.Diff Recovery Plan which outlines actions to be
taken in 2013-2014 to reduce the number of C.Diff cases with the aim of achieving the very
challenging target set of 1no more than 12 cases in 2013-2014.
b. Serious & Adverse Incidents (SIs)
We see that an important step to improve the quality of care for our patients is to learn from past
clinical incidents. One way to achieve this is to have a culture in place where staff are comfortable
to report incidents and are eager to implement any required changes.
Serious Incidents
To ensure that the Trust has a robust and effective serious incident investigation process in place
changes were implemented during 2011/12. The SI process now includes clear guidance on staff
responsibilities and lines of accountability for each step within the process. Education and training
programmes directed towards Investigation Officers has been provided using the NPSA Root
Cause Analysis framework. This will ensure that robust investigations are completed and
comprehensive reports are provided for presentation at Directorate and Corporate level meetings.
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| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
Quality Report
Template reports with guidance, action plans and application to close SI’s have also been
implemented which emphasis on the lessons learned from the SI which has occurred.
The aim will be that all lessons learned are implemented within 6 months of the publication of the
investigation report. The Incident Review Group will monitor the implementation of lessons learned
on a monthly basis, reporting to the Quality and Safety Committee.
During 2012 - 2013 there were a total of 88 Serious Incident (a reduction of 17 incidents reported
in 2011–2012) and these are classified as follows:
Category
2010 / 11
2011 / 12
2012 / 13
Infection Control
30
22
17
Clinical Care
25
54
38
Pressure Ulcer
22
26
33
Total Numbers
77
102
88
(Data taken from the Trust Safeguarding Incident Reporting System)
During January 2013, the Trust reported a National defined Never Event - retained foreign object
post operation. The incident involved the failure to remove a metal guide wire following a total hip
replacement surgery. The guide wire was detected post operatively following the first check x-ray
examination. The patient returned to theatre and the wire was removed successfully, the patient
went on to make a full recovery. The patient was made aware of the incident as soon as medical
staff were alerted to the wire remaining inset. The incident was subject to a full serious incident
investigation and a number of recommendations in relations to staff training and the inclusion of
guide wires on the surgical sterile trays made.
An important aspect which comes out of any serious incident investigations is the lesson learned.
The Trust has made some cultural changes whereby staff feel comfortable to report adverse
incidents and to implement changes required to bring about a safer hospital. This change has
come about by staff appreciating the benefits which come out of reporting incidents; that immediate
action can be taken in the more serious cases to prevent a repeat or by looking at patterns and
trends of minor incidents to make improvements.
The following is an example of some changes the Trust had made as a result of serious incident
investigation. Following an incident resulting in a delayed diagnosis, the Trust made changes
which allow radiologists to have protected time to undertake radiology reporting. The Directorate
also strengthened the radiology discrepancy meetings to ensure robust review of radiology
reporting. The Trust has also invested in supporting and training staff in statement writing and
stressing the importance of good record keeping as a part of good care.
Adverse Incidents
There were a total number of 4279 adverse incidents reported to the “National Reporting and
Learning Service” between April 2012 to March 2013, although this is subject to reliance on staff
reporting all incidents and includes an element of local clinical judgement in the reported figures.
The following graph demonstrates the top 10 Cause Groups that incidents reported in the 12
month comparison by cause group and by month (this data is taken from MSFT Safeguard incident
reporting system).
Mid Staffordshire NHS Foundation Trust |
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Quality Report
April 2012 – March 2013
Top 10 Cause Groups By Incident Type – April 2012 to March 2013
900
800
700
600
500
400
300
200
2012 Apr
2012 May
2012 Jun
2012 Jul
2012 Aug
2012 Nov
2012 Dec
2013 Jan
2013 Feb
2013 Mar
2012 Sep
Slips/Trips/Falls – Patient Incidents 1 April 2012 to 31 March 2013
Pressure Ulcer (admitted with) Incident – 1 April 2012 to 31 March 2013
60
50
40
30
20
10
0
May
Jun
Jul
Aug
Sep
2012
36
| Mid Staffordshire NHS Foundation Trust
Oct
Nov
Dec
Jan
Feb
2013
Mar
Staffing Level
Slips/Trips/Falls
- Patient
Pressure Ulcer
- Hospital Acqu
Pressure Ulcer
- Admitted
From
Medication
Laboratory
Sample Error
Documentation
Clinical Care
Admission,
Transfer,
Discharge
0
Communication
100
2012 Oct
April 2012 – March 2013
Quality Report
Staffing Level Incidents - 1 April 2012 to 31 March 2013
60
50
40
30
20
10
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
2012
Feb
Mar
2013
Medication Incidents – 1 April 2012 to 31 March 2013
60
50
40
30
20
10
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
2012
Feb
Mar
2013
Admission, Transfer, Discharge Incident – 1 April 2012 to 31 March 2013
50
45
40
35
30
25
20
15
10
5
0
Apr
May
Jun
Jul
Aug
2012
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2013
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Quality Report
April 2012 – March 2013
Adverse Incidents Levels 4 and 5
All level 4 and 5 adverse incidents are reviewed at the Clinical Directorate Governance meetings.
At these meetings, the grading may be reviewed and changed following peer discussion. The
main purpose of these discussions is to identify if there are any lessons learned and identify
actions required to reduce the likelihood of a repeat incident occurring.
During the reporting period, April 2012 to March 2013 the Trust reported 73 (1.7%) level 4 and 43
(1.0%) level 5 adverse incidents (the most serious) – full year figures are yet to be verified. The
Trust has made changes to its reporting system in 2012 to ensure consistency of definitions with
those used by the National Patient Safety Agency. During 2012, the National Confidential Enquiry
into Patient Outcomes and Death (NCEPOD) report, ‘Time to Intervene?’ recommended that
hospitals submit an adverse incident form following a patient cardiac arrest episode. We
implemented this recommendation in full which meant for a time the Trust was possibly reporting a
higher level of serious / death incidents to those hospitals that had yet to implement the
recommendations. The Trust altered its reporting of such incidents on advice from the Department
of Health and now only includes those where there is a suggestion that sub-optimal care may be
contributed to the incident. Examples of the other level 5 incidents included reported stillbirths;
patient falls resulting in a bone fracture requiring surgical intervention or a surgical complication.
A number of level 4 / 5 adverse incidents, but not exclusively, will be investigated by the Trust as a
Serious Incident. The Trust has a separate policy to follow in such circumstances. The Trust
provides a summary of all Serious Incidents and Adverse Incidents in reports presented to the
Trust Board on a monthly basis.
c. Falls
Reducing the number of falls our patients have whilst in our care has continued to remain a key
area of our work throughout 2012-2013.
The 2012-13 position on falls and the ongoing work to reduce the number of falls and, in particular,
those falls that cause harm to our patients is described below.
In 2012-2013 there were 745 patient falls; this was higher than in 2011 when the Trust had 647
falls. Reported rates of falls in acute hospitals range from 0 to 10 falls per 1,000 bed days. In 2012
the ratio of falls to bed days was 6.37 per 1,000 bed days compared to 5.5 per 1,000 bed days in
2011. The NPSA (2009) ratio is 5.6 per 1,000 bed days.
Figure 1 - Falls per 1000 bed days
Falls per 1,000 bed days
Falls per 1,000 bed days 2012-2013
38
8
7.5
7
6.5
6
5.5
5
4.5
4
MSFT Falls per 1000
bed Days per month
National Target
Falls per 1,000 bed
days YTD
| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
Quality Report
There were 10 patients who suffered serious harm (i.e. fractures) during 2012-13. There is still
significant work to be done to prevent falls and to ensure that our patients do not suffer serious
harm whilst in our care.
There has been a focus on Falls Training for staff across all the inpatient areas in the Trust during
2012-2013. As a result 72% of nursing staff, 65% of Physiotherapists and 100% of Occupational
Therapists having received falls training. All wards have falls champions. These are staff that have
received additional training and subsequently deliver training in their clinical areas and support
staff by raising awareness about strategies to reduce falls.
The falls care bundle has been implemented on wards with high levels of falls. Further roll out of
the care bundle will continue in 2013-2014. Slipper socks were trialled in several of the wards with
high numbers of falls and these have now been implemented across the Trust to replace the foam
slippers previously used for patients who do not have footwear.
A Falls Strategy and Trust wide action plan has been developed and will be implemented in 20132014.
3.2
Clinical Effectiveness
a. Nursing Quality Assurance System (NQAS)
In April 2012 a new electronic system (NQAS) for the collection of the monthly Nursing Quality
Assurance data was implemented in the Trust. This replaced the paper based system previously
used to collect this audit data. NQAS audits are undertaken monthly by the clinical nursing teams.
The data provides a baseline for the quality of care within the clinical area and identifies categories
which require actions to improve the quality of that care. Figure 1 shows the performance against
the NQAS categories for all adult wards for 2012-2013. This shows that overall for 2012-2013 the
90% compliance target was achieved for all these categories.
During Q2 of 2012-2013 NQAS categories were developed for specific specialities which included
the Emergency Department, Paediatrics and Maternity. These have been collected monthly since
September 2012. During 2013 the aim is to develop NQAS categories to allow data collection in
ITU and Outpatients.
NQAS audit results regarding the quality of nursing care across the Trust are reported monthly to
the Trust Board. The NQAS has now been incorporated
into the development of Ward Nursing
Quality Indicator Dashboards. These dashboards triangulate all aspects of Patient Safety, Quality
and patient experience and provide a holistic picture of all aspects of quality for each ward.
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Quality Report
April 2012 – March 2013
b. Venous Thromboembolism (blood clots)
This is a nationally mandated CQUIN which aims to reduce avoidable death,
chronic ill health from venous-thromboembolism (VTE).
disability
and
The national monthly target for the CQUIN target is that 90% of patients will have a completed risk
assessment within 24 hours of admission; this is applicable across all adult inpatient areas
including day cases, maternity, elective and non-elective admissions. The Trust has achieved this
target for each consecutive month in 2012-2103.
VTE Risk Assessment
98
96.5
96.4
96
96.4
96
95.2
95.1
94
93.8
90
90
90
90
90
90
90
94.1
92.9
92
90
96.1
95.4
94.9
90
90
MSFT
90
90
90
Target
88
86
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
March
(Taken from MSFT BI reporting system)
The validated Trust performance for VTE risk assessment within 24 hours is shown in Appendix A
Throughout 2012-2013 audits of VTE prophylaxis for patients assessed as being at risk were
undertaken monthly. The target is that 100% of patients assessed as at risk will receive
prophylaxis. VTE prophylaxis is included as a Key Performance indicator for 2013-2014 and results
will be reported to the Hospital Quality Assurance Committee and CCG monthly.
Month
April
May
June
July
August
September
October
November
December
January
February
March
Patients assessed as at risk of VTE who
received appropriate prophylaxis (target
100%).
95%
99%
100%
100%
98.60%
100%
100%
100%
100%
99%
100%
100%
c. Reducing our Hospital Standardised Mortality Ratio (HMSR)
We said that we would reduce our mortality rate and maintain this position.
We use the Dr Foster data which shows that the hospital has one of the lowest mortality rates of
any comparable hospital. The HSMR/SMR is one indicator of healthcare quality that measures
whether the death rate at a hospital is higher or lower than expected.
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April 2012 – March 2013
Quality Report
Mortality ratios are calculated by an independent company, Dr Foster Intelligence, from routinely
collected hospital data. HSMR/SMR compares the expected rate of death in a hospital with the
actual rate of death. Dr. Foster’s Intelligence system looks at those patients with diagnoses that
most commonly result in death, for example, heart attacks, strokes or broken hips – HMSR and all
deaths - SMR.
For each group of patients Dr. Foster calculates how often, on average across the whole country,
patients survive their stay in hospital, and how often they die. Whilst, in itself, the HMSR/SMR is
not a single marker of the quality of care, it is a useful barometer by which the Trust can compare
itself with other hospitals. In conjunction with the other indicators, this helps assess the quality of
care that is offered to our patients.
The Trust continues to have less patient deaths than would normally be expected by a Trust of its
size. An HSMR/SMR below 100 means that the Trust had fewer deaths than would be expected,
given the types of cases treated. Trusts with a rate above 100 will have had more deaths than
would be expected.
The Trust mortality rates continue to be reported as better than expected. The most up to date
information available - as at December 2012 the Trust relative risk score = 89.6 for the month and
‘as expected’ (51 deaths - Dr Foster ‘expected’ figure 56.9). The Rolling 12 month figure for HSMR
is 77.5 (statistically significantly low). This graph is based upon the HSMR 56 diagnosis basket. It
shows a consistent value of SMR below 100, the national average. This data represents elective
and non-elective deaths combined together. This suggests that the low mortality HSMR is
statistically significant for the 12 month period.
Mid Staffordshire NHS Foundation Trust |
41
Quality Report
April 2012 – March 2013
Mortality from all Activity Jan 12 to Dec 12
The overall 12 month SMR is 74.9 (statistically significantly low). This graph is based upon the
SMR values for all diagnoses. It shows a consistent value of SMR below 100, the national average.
This data represents elective and non-elective deaths combined together. This suggests that the
low mortality SMR is statistically significant.
No standardisation of the data has taken place. It is based upon the number of deaths within
hospital divided by the number of discharges. There has been a consistent reduction in the crude
mortality over the last 5-year period.
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| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
Quality Report
Mortality Best Performers / MSFT comparisons all activity last 12 months
In the group of 10 peers (best performance nationally) Mid Staffs was 4th lowest in regards to SMR
figures for all activity (elective + non-elective). This data is statistically significantly positive as the
confidence interval is small and the upper and lower limits are below 100.
How is this measured?
The Trust Board is committed to thoroughly investigating every death which occurs in our
hospitals. Clinicians review each death which occurs and ensures that learning is shared across
the organisation. These reviews are scrutinised by the Clinical Directorates and at the Mortality
Review Group who reports to the Healthcare Quality Assurance Committee. The Mortality Review
Group also reviews any mortality red bells alerts which may be published by Dr Foster. This gives
assurance to the Trust Board and supports clinicians and managers to implement any required
changes in clinical practice.
The Trust uses the Dr Foster alerts system and unusual statistical results are scrutinised and
investigated. All clinicians are encouraged to review their own patient outcomes through the use of
the Dr Foster system and benchmark their performance to national standards.
Mid Staffordshire NHS Foundation Trust |
43
Quality Report
3.3
April 2012 – March 2013
Patient Experience
Improving patient experience is central to our Trust values and involving the local community in
planning and assessing our care is a priority. To facilitate this we use a wide range of feedback
methods including compliments, electronic and paper surveys, on-line postings, announced and
unannounced visits by Governors, post discharge telephone calls, peer and national reviews and
complaints. Our local community expert groups such as Monthly Alzheimer’s Support Evening
(MASE), Deafvibe, Jigsaw and Rockspur and Assist have been very helpful in providing feedback
from their members.
a. Friends and Family Net Promoter Question
The local public chairs both our Patient and Carer Council and Complaints Focus Group, as we
believe both hospitals belong to the community and their involvement is crucial. The Hospedia
system offers patients the opportunity to provide real time patient feedback via the 360 bedside
television units throughout the hospital on both sites. The seventeen questions were agreed for the
commencement of the Patient Experience CQUIN, which commenced on April 1st 2012. From 1st
April 2012 to 31st March 2013, a total of 4,146 patients have provided feedback via Hospedia,
3,240 from Stafford hospital and 906 from Cannock hospital. The results are RAG rated to
measure effectiveness and improvements.
Mid Staffs Trust was one of the pilot sites for the implementation of the Friends and Family test in
the NHS Midlands and East SHA Cluster. A single question was asked to identify if our inpatients
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| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
Quality Report
would recommend our service to their family and friends providing a Net Promoter Score to
measure response. The wording of the question and the responses were set to standardise the
data collection. The Net Promoter Score also provides clear information for patients and the public,
which can influence choice in line with the NHS Outcomes Framework. Our Net Promoter score for
2012/13 increased by fifteen points against a CQUIN requirement of a ten point improvement.
Friends and Family Net Promoter Question: Trust Comparison by Month
Date
Net
Promoter
Score
(to nearest
decimal
point)
Promoter
Responses
Passive
Responses
Detractor
Responses
Patients Likely
or Extremely
Likely to
Recommend
Our Hospital
April 2012
41
54%
32%
13%
86%
May 2012
56
63.42%
28.71%
7.85%
92.13%
June 2012
52
62.47%
27.50%
10.02%
89.97%
July 2012
56
63.47%
29.21%
7.30%
92.68%
August 2012
54
62.76%
28.45%
7.97%
91.22%
Sept. 2012
58
66.07%
26.11%
7.81%
92.18%
October 2012
51
59.88%
31%
9.05%
90.88%
Nov. 2012
60
65.59%
28.96%
5.48%
94.55%
Dec. 2012
51
59.54%
31.50%
8.96%
91.04%
Jan. 2013
60
66.89%
26.56%
6.55%
93.44%
Feb. 2013
58
62.88%
32.01%
5.09%
94.89%
March 2013
66
72.01%
21.90%
6.07%
93.91%
Mid Staffordshire NHS Foundation Trust |
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Quality Report
April 2012 – March 2013
Family and friends Net Promoter Question April 2012-March 2013: Comparison of
data between wards and clinical areas
Ward
Net
Promoter
Score
Promoter
Responses
Passive
Responses
Detractor
Responses
Patients Likely
or Extremely
Likely to
Recommend
Our Hospital
Hilton Main
91
92%
7%
1%
99%
Acute Cardiac
Unit
67
68%
31%
1%
99%
SAU
70
72%
26%
2%
98%
Ward 6
64
67%
30%
3%
97%
Littleton
72
77%
18%
5%
95%
T&O
59
64%
31%
5%
95%
Ward 1
60
66%
28%
6%
94%
Fair Oak
63
70%
23%
7%
93%
Ward 2
56
64%
28%
8%
92%
Ward 7
54
62%
30%
8%
92%
Ward 8
48
57%
34%
9%
91%
Ward 10
48
59%
30%
11%
89%
Shugborough
33
46%
41%
13%
87%
Ward 12
49
63%
23%
14%
86%
Acute Medical
Unit
40
54%
32%
14%
86%
Please note: These responses are collected from Hospedia and paper surveys.
b. National Inpatient Survey by the CQC
The Care Quality Commission Survey of Adult Inpatients 2012 was carried out by the Picker
Institute with a total of 432 patients from Mid Staffs returning a completed questionnaire, providing
a response rate of 52%.
Compared to the 2011 survey Mid Staffs have scored significantly BETTER on 9 questions and
significantly worse on none.
Each of the 70 individual questions are grouped into one of 10 sections. Mid Staffs average score
in each section was greater than the national average score in 7 of the 10 sections equal to the
national average in 1 section and worse than the national average in 2 sections.
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| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
Quality Report
Our patient experience priorities for improvement 2013/14





To increase the number of responses to the patient experience questionnaire from 15% to
20% in all in-patient areas.
To gain a response to the Net Promoter question from at least 20% of all A&E attendees.
To rollout the Net Promoter question to all maternity patients from September 2013
To improve feedback from relatives and carers.
To continue to develop specialty specific focus groups.
There was also a nationally mandated CQUIN based on the annual inpatient survey produced by
the Picker Institute.
The CQUIN was based on a composite score calculated from 5 of the survey questions, each
describing a different element of the overarching theme “responsiveness to personal needs”.
These questions were:





Were you involved as much as you wanted to be in decisions about your care and
treatment?
Did you find someone on the hospital staff to talk to about your worries and concerns?
Were you given enough privacy when discussing your condition and treatment?
Did a member of staff tell you about medication side effects to watch for when you went
home?
Did hospital staff tell you who to contact if you were worried about your condition or
treatment after you left hospital?
The results for the 2012 Inpatient Survey showed an improvement across all 5 survey questions
outlined in the survey.
Composite CQUIN
Score
Trust
Year
Q1
Q2
Q3
Q4
Q5
National
2012
55
38
74
38
67
Mid Staffs
2012
74.7
64.3
84.6
54.7
79
71.5
Mid Staffs
2011
71
62.5
81.5
46.6
78
67.9
Mid Staffs
2010
70.2
60.4
78.1
48.1
75
66.4
The table also shows the Trust performance for these 5 questions against the national results. This
shows that the Trust performance was better than the national average response for these
questions.
The Trust’s performance for patient experience performance for the previous 3 years in shown in
Appendix A and demonstrates year on year improvement.
c. Complaints
2012-2013 saw a reduction in the number of complaints by 20%. This year we have exceeded our
target of 30% to achieve 161 fewer complaints received, equating to a 33% reduction.
We are not complacent about the reduction in the number as we understand that every complaint
reflects a poor experience for someone, however when in the context of increasing numbers of
compliments and improvement feedback around patient experiences, our pro-active approach of
Mid Staffordshire NHS Foundation Trust |
47
Quality Report
April 2012 – March 2013
giving patients and families the opportunity to tell us what they feel about our services in real time,
appears to be helpful for them.
Key themes identified in the complaints are shown below:
2012/2013
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Communication
Communication
Communication
Communication
Medical Care
Medical Care
Medical Care
Nursing Care
Staff Attitude
Diagnosis missed/
delayed /wrong
Staff Attitude
Medical Care
Outpatient appointments
delays/ Cancellations
Staff Attitude
Discharge, and Admission
arrangements
Discharge and Admission
arrangements
Diagnosis missed/
delayed /wrong
Nursing Care
Nursing Care
Attitude of Staff
Unlike other organisations we have been committed to investigating complaints as far back as
2005, rather than just for the last year as legal and national guidance.
Our “Speaking up” campaign is coming to the end of a two and a half year pilot program in
collaboration with the Patient Association, NCEPOD and the Pilgrim Project (Patient Voices) which
looked at improving the quality of our complaints investigations, outcomes and learning. We were
pleased to note that one element of the project, using the standards for a panel to retrospectively
analyse complaints handling, has been recommended to be taken forward nationally as part of the
Robert Francis Report.
Strengthening the quality of the investigation and training has impacted on response times,
particularly for more complex complaints, but we expect this to improve significantly going forward.
To ensure that we involve service users and the community, we hold monthly Patient Focus Group
Meetings with members of the public who have previously had cause to complain about our
service. During this meeting our complaint reports are shared and discussed, specific complaint
issues can be raised and ways in which they might be addressed are explored. These meetings
provide a valuable resource for the complaints procedure to ensure that we do not lose sight of
what is important to the complainant themselves.
d. PROMs Performance April-June 2012
PROMs are Patient Reported Outcome Measures. The NHS is asking patients about their health
and quality of life before they have an operation, and about their health and the effectiveness of the
operation afterwards. This will help the NHS measure and improve the quality of its care.
The Trust performed 220 eligible procedures April – June 2012 of these 209 completed the preoperative questionnaire and 209 post operative questionnaires were issued. Quality Health were
able to link 10 of 209 returned post operatively questionnaires, giving a linkage rate of 45.9% and a
raw response rate of 37.0%.
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| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
Participation Rates
Pre Operative
Participation Rates
Post Operative
Quality Report
Total eligible
episodes
Q1s completed
Participation
rate
Q1s linked
Linkage
rate
220
209
95.0%
96
45.9%
Q1s
completed
Q2s sent to
date
209
27
Issue rate
Q2s returned
to date
Raw
response
rate
12.9%
10
37.0%
Average Health Gain PROMS performance data for MSFT is included in Appendix A.
3.4
Staff Survey
We want to be known as a good employer and to be able to demonstrate this by a year on year
improvement in the results of the staff surveys.
Our staff survey response rate for the 2012 survey was 61%. This response rate was in the top
20% when compared against other acute Trusts and was a significant improvement on the 49%
response rate achieved in 2011. It was also a record response rate for the Trust and provides
confidence that the overall results represent a reasonable picture of the way that staff perceives
their working life.
The staff survey showed improvement in:





Percentage of staff able to contribute towards improvements at work
Staff job satisfaction
58% of staff compared to 63% nationally would recommend the Trust as a place to
work or receive treatment; this was an improvement compared to 50% in 2011.
Percentage of staff appraised in last 12 months
Percentage of staff having equality and diversity training in last 12 months
The staff survey showed deterioration in:



Percentage of staff suffering work-related stress in last 12 months, 34% compared
to 25% in the previous year.
Percentage of staff working extra hours 71% compared to 63% the previous year.
Percentage of staff saying hand washing materials are always available
Mid Staffordshire NHS Foundation Trust |
49
Quality Report
April 2012 – March 2013
National Targets
Performance against the national targets in 2012-2013 is shown below:
Performance against key targets
2012/13
Target
2010/11
Actual
2011/12
Actual
2012/13
Actual
11.1
8.71
8.85
8.88
RTT - Admitted - 90% In 18 Weeks
90.00%
96.34%
87.09%
85.38%
RTT - Non-Admitted - 95% In 18 Weeks
RTT / Patient Experience - Maximum time of 18 weeks from
point of referral to treatment in aggregate – patients on an
incomplete pathway 92%
95.00%
99.32%
93.20%
93.82%
92.00%
97.16%
90.23%
94.71%
Cancer - 2 Week GP Referral To 1st Outpatient Appointment
93.00%
94.60%
92.90%
95.00%
Cancer - 31 Day Diagnosis To Treatment
96.00%
99.50%
99.70%
100.00%
Cancer - 62 Day Referral To Treatment From Hospital Specialist
95.00%
93.90%
86.70%
97.50%
Cancer - 62 Days Urgent Referral To Treatment
85.00%
88.40%
85.70%
87.79%
A&E 4 Hour Waits (Combined SGH And CCH)
A&E Service Quality Indicator - Unplanned A&E Re-Attendance
Rate
A&E 95th Percentile Wait Above 4 Hrs (Admitted + NonAdmitted)
95.00%
89.79%
92.08%
93.52%
5.00%
5.51%
6.08%
4.99%
239
397
396
292
A&E Service Quality Indicator - Left Without Being Seen
5.00%
3.36%
2.92%
0.90%
A&E Service Quality Indicator -Time To Initial Assessment
14
3
37
18
Time To Treatment - Median Wait
C.Diff Positive Samples (MSGH Patient Samples Only Incl RE
Samples) On Or After 4th Day Of Admission
Incidence Of MRSA Bacteraemia (MSHG Patient Samples Only
Incl RE Samples) On Or After 3rd Day Of Admission
60
181
54
38
24
35
26
25
1
2
2
0
surgery 94%
94.00%
100.0%
98.9%
100.00%
anti-cancer drug treatments 98%
98.00%
100.0%
100.0%
100.00%
N/A
N/A
N/A
N/A
85.00%
88.4%
85.9%
87.80%
NHS Cancer Screening Service referral 90%
Cancer: two week wait from referral to date first seen,
comprising:
90.00%
99.4%
99.0%
99.39%
all urgent referrals (cancer suspected) 93%
for symptomatic breast patients (cancer not initially
suspected) 93%
93.00%
94.6%
92.9%
95.00%
93.00%
93.6%
93.9%
92.71%
National Targets and Regulatory Requirements
RTT - Admitted - Median
Quality - All cancers: 31-day wait for second or subsequent
treatment, comprising:
radiotherapy 94%
Quality - All cancers: 62-day wait for first treatment from:
urgent GP referral for suspected cancer 85%
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| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
Quality Report
Explanation of variance in Performance against 2012-2013
Improving waiting times for patients- 18 week target
The 18 week target for patients to be treated from the time of referral to receiving their first
treatment was not achieved for both our admitted and non admitted patients on a Trust wide level.
There was a marked improvement from September 2012 onwards with the Trust delivering the
Admitted, Non Admitted and Incomplete targets and sustaining this until year end. This was mainly
down to gaining a better understanding of our demand and capacity and targeted waiting lists to
clear any long waiting patients. At the beginning of 2012 the Trust had 301 patients waiting over 52
weeks; by July 2012 this was 0 and has been the case since. This is an important target and
patients have a legal right to treatment within eighteen weeks so, working with our primary care
trusts, we have taken a number of actions to ensure that the waiting time for our patients for
treatment is low as possible, which include weekly Demand & Capacity meetings and also Monthly
Performance review meetings. All patient pathways are validated on a regular basis as well. The
current average waits are;
 Admitted- 9.98 weeks
 Non Admitted- 4.89 weeks
 Incomplete 4.06 weeks
Cancer Waiting Times
The Trust has made further progress in relation to cancer targets for 2012/13 which is reflected in
the levels of care offered to patients. Achievement of some cancer targets is particularly complex
due to the requirement for timely patient referrals from other healthcare providers. In any case, the
Trust achieved all of the cancer standards for the year, with the exception of the 2 week Breast
symptomatic referral. An action plan has been developed and enacted, with the Trust achieving for
the first month of the new financial year.
Accident and Emergency Target
The Trust delivered the Accident and Emergency Target for 8 of the first 9 months from the start of
the financial year with the exception being May’12. As a Trust we ensured that there was a
continued executive focus on improving patient flow indicators (30% by 11am, Weekend
Performance, Long Stay Patients) However from the middle of December until the middle of
February there was an increased demand and continuous pressure across the Local Health
Economy.
Mid Staffordshire NHS Foundation Trust |
51
Quality Report
4.
April 2012 – March 2013
Statement of Directors' Responsibilities In Respect of
the Quality Report
The Directors are required under the Health Act 2009 and the National Health Service (Quality
Accounts) Regulations 2010 to prepare Quality Accounts for each financial year. Monitor has
issued guidance to NHS foundation trust boards on the form and content of annual Quality Reports
(which incorporate the above legal requirements) and on the arrangements that foundation trust
boards should put in place to support the data quality for the preparation of the Quality Report.
In preparing the Quality Report, Directors are required to take steps to satisfy themselves that:


The content of the Quality Report meets the requirements set out in the NHS Foundation
Trust Annual Reporting Manual;
The content of the Quality Report is not inconsistent with internal and external sources of
information including:
Board minutes and papers for the period April 2012 to May 2013
Papers relating to Quality reported to the Board over the period April 2012 to March 2013
Feedback from local health watch organisations dated 28 May 2013
Feedback from Staffordshire Health Scrutiny Committee dated 28 May 2013
Feedback from the commissioners dated 29 May 2013
The Trusts complaints report published under regulation 18 of the Local Authority Social Services
and NHS Complaints Regulations 2009
The 2012 national patient survey
The 2012 national staff survey
The Head of Internal Audits annual opinion over the Trusts control environment dated 29 May 2013
Care Quality Commission quality and risk profiles, latest dated 4 April 2013







The Quality Report presents a balanced picture of the Trusts performance over the period
covered;
The performance information reported in the Quality Report is reliable and accurate;
There are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Report, and these controls are subject to review to confirm
that they are working effectively in practice;
The data underpinning the measures of performance reported in the Quality Report is robust
and reliable, conforms to specified data quality standards and prescribed definitions, and is
subject to appropriate scrutiny and review;
The Quality Report has been prepared in accordance with Monitor’s annual reporting guidance
(which incorporates the Quality Accounts regulations) published at www.monitornhsft.gov.uk/annualreportingmanual as well as the standards to support data quality for the
preparation of the Quality Report.
The directors confirm to the best of their knowledge and belief they have complied with the
above requirements in preparing the Quality Report.
The powers of the Governors were transferred to the TSAs upon their appointment and it is
not considered appropriate for the TSAs to provide the Governors’ commentary, therefore this
requirement has been removed from the above.
Mr Alan Bloom
Trust Special Administrator
Date: 29 May 2013
52
| Mid Staffordshire NHS Foundation Trust
Lyn Hill-Tout
Chief Executive
April 2012 – March 2013
Quality Report
Appendices
Appendix A - MSFT Performance against the Nationally Mandated set of
Quality Indicators
The Trust’s performance against the eight nationally mandated set of quality indicators applicable
to acute trusts are outlined below:
1. Mortality
1. Summary of
Hospital Level
Mortality
Indicators(SHMI)
value
SHMI banding
2. Percentage of
patients deaths
with a
palliative care
coded at
diagnosis or
speciality level
MSFT period
April 2010March 2011
MSFT period
April 20112012
National
period
April 20112012
0.9852
0.9087
1
2
23.8%
2
25.7%
N/A
18.9%
National
National Best
Worst
Performance
Performance
Comments
July 2011-June
July 2011-June
2012
2012
0.7108
1.2559
MSFT considers
that this data is a
described for the
following reason:
It is the latest data
available on the
1
3
HSCIC website
0.3%
46.3%
MSFT intends to
take the following
actions to improve
the indicators and
percentages
A programme
of mortality
reviews
undertaken on
a monthly
basis.
Joint mortality
review
meetings with
the Clinical
Commission
Group
Targeted
mortality
reviews.
Expansion of
review of deaths at
Directorate and
Speciality level.
Mid Staffordshire NHS Foundation Trust |
53
Quality Report
2. Patient Reported
Outcome Measures
(PROMs)- Average
Health Gain
April 2012 – March 2013
MSFT
April 2010March 2011
Groin hernia surgery
Varicose veins surgery
Hip replacement
Knee replacement surgery
0.087
N/A
0.373
0.295
National
(England)
National Best
Provider
April 2010March 2011
0.085
0.091
0.405
0.299
0.156
0.155
0.503
0.407
National
Worst
Provider
April 2010March 2011
-0.020
-0.007
0.264
0.176
Comments
MSFT considers that
this data is a described
for the following
reason:
It is the latest data
available on the HSCIC
website
MSFT intends to take
the following actions
to improve the
indicators and
percentages
The PROMs for Hip
Replacement and Knee
replacement surgery
have been included as
part of the enhanced
recovery CQUIN for
2013-2014. This will
place a greater
emphasis on these
PROMs and they will
be reported quarterly
to the Hospital Quality
Assurance Committee
and CCG as part of the
CQUIN reporting and
monitoring schedule.
(The HSCIC web site does not do the banding 0-14 and 15+ that the quality accounts guidance states).
3. Readmissions
to hospital
within 28 days
MSFT
April 2009March 2010
Patients
0-15 12.54%
years of age
readmitted to
hospital which
forms part of
the Trust within
28
days
of
discharge from a
hospital which
forms part of
the Trust
Patients
16+ 9.94%
years of age
readmitted to
hospital which
forms part of
54
National
MSFT
(England –
April 2010- Small Acute)
March 2011 April 2010March 2011
12.56%
10.19%
10.39%
11.89%
| Mid Staffordshire NHS Foundation Trust
National
National Best
Worst
Performance
Performance Comments
(Small Acute)
(Small Acute)
0%
0%
12.75%
12.7%
MSFT considers that
this data is a described
for the following
reason:
It is the latest data
available on the HSCIC
website
MSFT intends to take
the following actions to
improve the indicators
and percentages:
The Trust has a
readmissions group
which meets monthly
April 2012 – March 2013
the Trust within
28
days
of
discharge from a
hospital which
forms part of
the Trust
Quality Report
and reviews high level
data on readmissions
from our own sources
and Dr Foster's.
Departments with a
higher than expected
rate of unplanned
readmissions are
identified and a senior
clinician asked to
conduct an audit, share
learning and put in
place actions to reduce
readmissions.
We also, using Dr
Foster's data identify
conditions with a higher
than expected
readmissions rate and
follow a similar process.
4.
Responsivenes
s to personal
needs –
National
National
average
National
MSFT
MSFT
MSFT
Best
Worst
weighted score
(England)
April 2009- April 2010- April 2011Performance Performance Comments
of 5 questions
April 2011March 2010 March 2011 March 2012
April 2011- April 2011from the
March 2012
March 2012 March 2012
National
Patient Survey
(score out of
100)
62.3
66.4
67.9
67.4
85.0
56.5
MSFT considers that
this data is a
described for the
following reason:
It is the latest data
available on the
HSCIC website
MSFT intends to
take the following
actions to improve
the indicators:
Include monthly
patient survey
feedback in the
Ward Quality
Dashboards.
Patient experience
feedback to be
displayed for all
clinical areas and
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Quality Report
April 2012 – March 2013
Ward managers to
take actions based
on this feedback
5. Staff who would
recommend the
Trust as a provider
of care to their
family & friends
MSFT
2011
MSFT
2012
National
(England)
2012
National
Best
Performance
2012
National
Worst
Performance
2012
Comments
52
58
63
94.20
35.34
MSFT considers that this
data is a described for
the following reason:
It is the latest data
available on the HSCIC
website.
MSFT intends to take
the following actions to
improve the
percentages:
Ward Managers to
raise the profile of
the good work done
in their wards
Continue wide
publication of
performance
reports showing
improvements in
patient care
Wards to promote
successes monthly,
through internal
communication
channels
Continue
publication of
complimentary
messages from
patients via daily
‘Hot News’ email
6. Venous
thromboembolism
(VTE) risk
assessment
56
MSFT
Q1 20122013
MSFT
Q2 20122013
MSFT
Q3
20122013
National
Q3 20122013
96.1%
95.7%
94.2%
94.2%
| Mid Staffordshire NHS Foundation Trust
National
Best
Performance
Q3
20122013
100%
National
Worst
Performance
Q3
20122013
84,6%
Comments
MSFT considers that
this data is a described
for the following
reason:
It is the latest data
available on the HSCIC
website
April 2012 – March 2013
Quality Report
MSFT intends to take
the following actions
to improve this
percentages:
Continue to ensure
that all patients have a
VTE risk assessment
undertaken within 12
hours of admission
Ensure that all patients
assessed as at risk have
prophylaxis
Undertake RCAs on all
hospital acquired VTE
(VTE section in Part 3
of this Quality Account
2013-2014)
7, C.Difficile Infection
(per 100,000 bed
days)
MSFT
2010/11
MSFT
2011/12
National
2011/12
28.2
21.0
21.8
National
Best
Performance
2011/12
0
National
Worst
2011/12
Comments
51.6
MSFT considers that this
data is a described for the
following reason:
It is the latest data
available on the HSCIC
website
MSFT intends to take the
following actions to
improve this rate by
continuing to reduce
C.Diff infections through
implementation of the
C.Diff Recover Plan ( See
Reducing Hospital
Acquired Infections in Part
3 of the Quality Account
2013-2014)
8. Incidents
MSFT
April 2011Sept 20111
National
(Small
Acute)
7.18
MSFT
Oct
2011March
2012
6.93
Incident reporting
rate per 100
admissions
Number of Safety
Incidents that result
in severe harm or
death
Rate of patient safety
incidents that result
in severe harm or
National
Worst
(Small
Acute)
Comments
7.30
National
Best
Performance
(Small
Acute)
3.36
17.46
7
86
0
15
MSFT considers that this
data is a described for the
following reason:
It is the latest data
available on the HSCIC
website
10
0.03
0.02
0.01
0
0.11
MSFT intends to take the
following actions to
improve the indicators
Mid Staffordshire NHS Foundation Trust |
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Quality Report
death (per 100
admissions
58
| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
and percentages
Continuing the
implementation
of the Quality &
Safety Strategy
Continued
implementation
of targeted
patient safety
programme –
medication
errors, inpatient
falls, pressure
ulcers
Implementation of
Patient Safety First
programmes
April 2012 – March 2013
Quality Report
Appendix B – Care Quality Commission Core Standards
Involvement and Information
Respecting and Involving People who use Services
Consent to Care and Treatment
Personalized Care, Treatment and Support
Care and Welfare of People who use Services
Meeting Nutritional Needs
Co-operating with Other Providers
Safeguarding and Safety
Safeguarding People who use Services from Abuse
Cleanliness and Infection Control
Management of Medicines
Safety and Suitability of Premises
Safety, Availability and Suitability of Equipment
Suitability and Staffing
Requirements Relating to Workers (Training, Suitability, Registration etc)
Staffing (Numbers etc)
Supporting Workers
Quality and Management
Assessing and Monitoring the Quality of Service Provision
Complaints
Records Management
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Quality Report
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April 2012 – March 2013
April 2012 – March 2013
Quality Report
Independent Auditor’s Report on the Annual Quality Report
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Quality Report
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| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
April 2012 – March 2013
Quality Report
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Quality Report
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April 2012 – March 2013
April 2012 – March 2013
Quality Report
Stakeholders Commentary on the Annual Quality Report
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Quality Report
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| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
April 2012 – March 2013
Quality Report
Statement from Healthwatch Staffordshire
Introduction
Overall it was felt that the document was clear and well presented, although some tables lacked
clarity. It provided good information on how the Trust had performed during 2012/13 and
demonstrated visible improvement from the previous year in some areas but it was also noted that
in some areas performance had deteriorated. In relation to benchmarking against other similar
Trusts the Mid Staffordshire NHS FT was performing better than average in relation to mortality
rates and the number of hospital acquired pressure sores although for the latter it should be noted
that the number of grade 3 pressure sores had risen from the previous year. Performance against
key national targets was variable.
General Comments
Overall the document presented a Trust that is striving to drive up quality of care and improve
patient experience. The latter is supported by their success on the net promoter score and the
results of the in-patient survey. The Trust acknowledges that there are areas where further
concentrated efforts are need in order to ensure that its performance meets national targets and
that it achieves the level of performance required by the Commissioners through the CQUINs.
Achievement of the CQUINs will also ensure that the Trust maximises its income.
Specific Comments
It was noted that the number of falls experienced in 2012/13 had increased over the previous year
but we were reassured that the Trust is implementing a number of actions to address this including
staff training and use of Ward Quality Dashboards.
The Trust are disappointed that they have not made the achievement that they would wish in
relation to medication errors. One action to address this is the use of medicine lockers by every
bed so that patients assessed as capable will be able to self-medicate. It has been shown that
taking this approach can improve compliance following discharge therefore there is an additional
benefit.
We were sorry to see that performance on End of Life Care was below the standard expected. We
were advised that the actions set out in the CQUIN had not been agreed until September/October
and therefore there was a significant delay in establishing the planned programme of training. This
has now been established in 3 wards with Ward 10 completed and the other 2 partially completed.
End of Life Care continues to be a CQUIN for 2013/14.
We noted that there is still some work to do in relation to ensuring that all patients with dementia
across all inpatient wards are appropriately identified in order to ensure that the manner in which
care is provided reflects the patients’ cognitive impairment. We were pleased to see that the Trust
appointed a Dementia Project Nurse earlier in the year to support this process.
The response to the staff survey of 61% was a very commendable rate. Examination of the staff
survey does indicate some issues in relation to staff involvement/engagement and motivation.
There was a view that the Quality Account could be more explicit regarding the strategy for staff
engagement and how staff experience can relate to patient experience (for example in additional
opportunities for training which are of benefit to both staff and patients). It is recognised however
that this is a very challenging time for all staff.
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Quality Report
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Other areas to note in respect of the continuing drive for quality include:
The change to the Ward Sisters’ role which has seen the clinical element (previously 60%
of the role) removed to allow them to be 100% supervisory.
The implementation of the Improvement Academy with 2 cohorts through in 2012/13 and 3
cohorts planned for the current year. This has been a contributory factor in changing the
culture of the organisation.
The assessment by the CQC which found the Trust overall compliant both in respect of
general services and maternity services
An issue was raised regarding the level of confidence the Trust has in accuracy of the data it
produces and the opportunities to test this. In response we were advised that if the Trust had
concerns it would conduct a peer review to test the data. It was also felt that the process of regular
audit would also identify variations.
Conclusion
Overall Healthwatch is of the view that the Trust is making considerable effort to improve the
quality of the service it provides which is exemplified in their strap line “Because we care”. That this
is being achieved against a background of high profile negative media is to be commended.
The Healthwatch representatives were pleased to have the opportunity to discuss the Quality
Accounts Report with Colin Ovington Director of Nursing and his Deputy Kara Blackwell and we
would like to thank them for the openness of their approach.
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| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
Quality Report
Commentary from Staffordshire Health Scrutiny
We are directed to consider whether a Trust’s Quality Account is representative and gives
comprehensive coverage of their services and whether we believe that there are significant
omissions of issues of concern.
There are some sections of information that the Trust must include and some sections where they
can choose what to include, which is expected to be locally determined and produced through
engagement with stakeholders.
We focused on what we might expect to see in the Quality Account, based on the guidance that
trusts are given and what we have learned about the Trust’s services through health scrutiny
activity in the last year.
We also considered how clearly the Trust’s draft Account explains for a public audience (with
evidence and examples) what they are doing well, where improvement is needed and what will be
the priorities for the coming year.
Our approach has been to review the Trust’s draft Account and make comments for them to
consider in finalising the publication. Our comments are as follows.
Introduction. We would like to see the Statement of Assurance and Statement of Quality from the
Chef Executive signed by the Chairman and the Chief Excecutive.The introduction to the Trust and
Quality could be more clearly identified and include who was involved in its development. The
introduction would also benefit from a full list of services provided by the Trust.
Priorities. We note the Priorities for 2013-2014 but would like to see the rational as to choice and
who was involved in the process. In relation to the CQUIN income, where the level of was not
achieved the inclusion of the reason for this would be helpful.
Review of Quality Performance. National Targets where they have not been achieved, what
actions have been taken to address this issue.
Additional comment from Councillor Patricia Rowlands – Chair Stafford Borough Council
Health Scrutiny Committee
I acknowledge receipt of the Quality Account, but on this occasion I wish to decline to make a
comment on the basis of the relatively short timescale in which to make an informed response and
the lack of in-house resources to advise on the analysis of healthcare organisational accounts
which are both technical and appear to be written for healthcare professionals”
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Quality Report
April 2012 – March 2013
Joint Statement from Stafford and Surrounds CCG and Cannock Chase CCG
Stafford and Surrounds CCG and Cannock Chase CCG are making this joint statement as the lead
commissioners for this provider. We are pleased to have the opportunity to comment on the
Quality Account for 2013.14
Many of the areas covered in the Quality Account document are reviewed at the monthly Clinical
Quality Review Meetings with the Trust where commissioners meet with the Trust to hold them to
account for the quality and safety of services, to agree any actions for improvement and obtain
assurance for current and prospective patients who may have need of their services.
Having read the quality account it is encouraging to note the improvements made in 2012/13 in
particular
Introduction of measures to pressure ulcers such as the SKIN care bundle and the pressure
relieving equipment library has enabled the Trust to reduce their pressure ulcer rate from
12.33 to 10.18. This continues to be a priority for reduction in 2013/14.
The Trust is to be commended for the pioneering work they have undertaken on the
management of complaints as a result of their “Speaking Up” campaign where they
developed standards for independent complaint review panels .
The net promoter score which specifically measures patient confidence in the hospital has
slowly and steadily increased the over the year to its highest score in March. Both the
results from the national inpatient survey and the national CQUIN for patient experience
were above the national average.
Maintenance of low rates of deaths compared to other comparable Trusts with their being
less deaths than expected.
Introduction of a Ward Nursing Quality Indicator Dashboard to triangulate all aspects of
patient safety and patient experience.
However there are some areas for further improvement such as the number of falls which have
increased despite a number of measures that have been introduced. There is also still some
concern around the patients being discharged with cannulas insitu although this has reduced from
the previous year. The Safe Guarding incidents related to the performance of a few staff have
been a cause for concern and the Trust have worked with commissioners to ensure that
appropriate and prevention action is taken to reduce the likelihood of reoccurrence. This will be an
area for continued surveillance.
Priorities for 2013/14
The commissioners support the priorities for 2013/14 outlined in the Quality Account as these are
based on improvements identified through quality and safety performance reviews and align with
clinical commissioning priorities. We note the Trust’s intention to review the quality dimensions of
the Francis Report and the associated review of governance arrangements.
To the best of the commissioner’s knowledge the information contained in the report is accurate.
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| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
Quality Report
Acronyms and Definitions
A&E
Accident and Emergency
AMM
Annual Members Meeting
AMU
Acute Medical Unit
ARAC
Audit, Risk & Assurance Committee
BME
Black and Minority Ethnic
CCG
Clinical Commissioning Group
CCU
Critical Care Unit
CIDS
Community Information Data Sets
CIP / CIPs
Cost Improvement Plan(s)
CIPFA
Chartered Institute of Public Finance and Accountancy
CNST
Clinical Negligence Scheme for Trusts
CoG
Council of Governors
CPT
Contingency Planning Team
CQC
Care Quality Commission
CQUIN
Commissioning for Quality and Innovation
CRES
Cost Releasing Efficiency Savings
CSIP
Clinical Service Implementation Plan
CT
Computer Tomography
DH / DoH
Department of Health
EBITDA
Earning before interest, tax, depreciation and amortisation
ENT
Ear, Nose and Throat
EPR
Electronic Patient Record
eTTO
Electronic To Take Out – Discharge Summaries
FIOP
Finance Investment and Operational Performance Committee
FT ARM
Foundation Trust Annual Reporting Manual
FTE / WTE
Full Time Equivalent / Whole Time Equivalent
FTGA
Foundation Trust Governors Association
GP
General Practitioner
HQAC
Healthcare Quality Assurance Committee
HR
Human Resources
HSMR
Hospital Standardised Mortality Ratio
IFRS
International Financial Reporting Standards
IM&T
Information Management & Technology
KF
Key Factors
LCFS
Local Counter Fraud Specialist
LHE
Local Health Economy
LLP
Limited Liability Partnerships
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Quality Report
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MRI
Magnetic Resonance Imaging
MRSA
Methicillin-Resistant Staphylococcus Aureus
MSFT
Mid Staffordshire NHS Foundation Trust
NCAPOP
National Confidential Audit Patient Outcome Programme
NCEPOD
National Confidential Enquiries of Patient Outcomes and Death
NHS
National Health Service
NHSLA
National Health Service Litigation Authority
NICE
National Institute of Clinical Excellence
NIV
Unit Non-Invasive Ventilation Unit
NPSA
National Patient Safety Agency
NVQ
National Vocational Qualification
PbR
Payment by Results
PCT
Primary Care Trust
PDT
Practice Development Team
PEAT
Patient Environmental Action Team
PFI
Private Finance Initiative
QIPP
Quality, Innovation, Productivity and Prevention
QRP
Quality Risk Profile
R&D
Research and Development
RAG
Red, Amber, Green
REACT
Rapid Emergency Assessment and Care Team
SAU
Surgical Assessment Unit
SHA
Strategic Health Authority
SLA
Service Level Agreement
TSA
UHNS
VTE
WTE
Trust Special Administrator
University Hospital of North Staffordshire
Venous Thromboembolism
Whole Time Equivalent
72
| Mid Staffordshire NHS Foundation Trust
April 2012 – March 2013
Quality Report
Accounting
Officer
Senior person appointed by the Treasury or designated by a Government
department to be accountable for the operations of an organisation and
the preparation of its accounts
Acute Trust
An NHS body that provides secondary care or hospital based healthcare
services from one or more hospitals
Annual
Governance
Statement
An annual statement of how the Trust has assured itself that it has taken
all reasonable steps to recognise the risk to its operational and strategic
goals and put in place mechanisms to mitigate, to an acceptable level, the
probability or impact of those risks.
Benchmarking
Process that helps practitioners to take a structured approach to share,
compare, identify and develop the best practice
Care pathway
Care Quality
Commission
(CQC)
A pre-determined plan of care for patients with a specific condition.
The independent regulator of health and social care
Carer
Person who provides a substantial amount of care on a regular basis, and
is not employed to do so by an agency of organisation. Carers are usually
friends or relatives looking after someone at home who is elderly, ill, or
disabled
In the process local authorities and Clinical Commissioning Groups
(CCGs) (previously Primary Care Trusts or PCTs) undertake to make sure
that services are funded by them meet the needs of the patient
Local services provided outside a hospital. Many community staff are
attached to GP practices and to health centres.
Commissioning
Community
Health Services
Council of
Governors
Foundation
Trusts
HM Treasury
KPMG LLP
Local Health
Economy
Monitor
National Quality
Board
Quality Accounts
RSM Tenon
Staffordshire LINk
Strategic Health
Authority
Tariff
UNISON
Those responsible for representing the interests of the NHS Foundation
Trust members, and partner organisations. They hold the Trust Board to
account.
NHS organisations that are run as independent, public benefit
corporations, which are both controlled and run locally
United Kingdom's economics and finance ministry
The Trust’s External Auditors
Monitor is the regulator of NHS Foundation Trusts
National Quality Board has been set up under the current reforms to
ensure that quality is at the heart of NHS activity
A self-assessment undertaken by providers of the quality of their care
services.
The Trust’s Internal Auditors
Local Involvement Network
The SHA is responsible for strategic supervision of these services,
however the Health and Social Care Act provides for the abolition of
SHAs, to be replaced by Clinical Commissioning Groups.
The fixed payment that covers roughly half of all hospital treatments
Public services and essential industries trade union. It represents
employees in local government, healthcare, the voluntary sector and
elsewhere. The largest trade union in the NHS.
Mid Staffordshire NHS Foundation Trust |
73
Company Secretary
Mid Staffordshire NHS Foundation Trust
Weston Road, Stafford, Staffordshire, ST16 3SA
Telephone: 01785 887534
Email: david.haycox@midstaffs.nhs.uk
Website: www.midstaffs.nhs.uk