North Tees and Hartlepool
NHS Foundation Trust
Annual Quality Account 2012-2013
Leading Into 2013-14
Annual Quality Account 2012-2013
Leading Into 2013-14
Our approach to Quality: an Introduction to this
Annual Quality Account from the Chief Executive
The Trust is pleased to present our annual Quality Account to demonstrate
our continued commitment to delivering high quality patient care. Whilst
there has been continued publicity about the quality of care provided to
some patients in hospitals in England and Wales over the last year, I am
always pleased to receive excellent feedback from our patients and their
relatives across both the community and hospital services we deliver, which
demonstrate to me that we strive to ensure that our patients receive high
standards of clinical care, delivered by caring, compassionate staff. I am
particularly pleased that patients have rated our hospitals as 4.5 to 5 star
services on NHS choices (January 2013); the average score across the North
East is 3.5.
Despite the challenging economic climate during 2012-2013, we remain committed
to maintaining quality and protecting frontline teams. We have continued to invest in,
and expand our training and development opportunities to provide staff with the skills,
technology and knowledge they need to meet the needs of patients and their families.
This, our third combined community and hospital service Quality Account, demonstrates
some of the actions we have taken during 2012-2013, and highlights actions we will be
taking over the forthcoming year to ensure our continued commitment to ensuring and
continuing to monitor and improve quality of care and patient experience.
Our quality strategy and our Quality Account indicate our priorities for the coming year. These
have been developed with patients, carers, staff, governors, commissioners and with key
stakeholders including health scrutiny committees, local involvement networks (LINks) and
healthcare user groups.
We believe and commit to Putting Patients First by making patient safety and experience our
number one priority every day.
2
Annual Quality Account 2012-2013
Contents:
Part 1:
Part 1
Statement on Quality from the Chief Executive
Part 2:
Part 2A
Performance against quality improvements priorities for 2012-2013
Part 2B
Quality improvement priorities for 2013-2014
Part 2C
Statement of Assurance from the Board
Part 3:
Part 3A Trust performance against additional Quality Performance Indicators
Part 3B
Performance from key national priorities from the Department of Health Operating Framework, Appendix B of the Compliance Framework
Part 3C
Department of Health Core indicator set
Annex 1 Third Party Declarations
Annex 2 Statement of Directors’ responsibilities in respect of the Quality Account
Annex 3 Independent Auditor’s Limited Assurance Report to the Council of Governors
Glossary Definition of some of the terms used within this document
3
Annual Quality Account 2012-2013
Part 1: Statement on Quality from the Chief Executive
Our quality pledge
In 2008, our Board and our staff pledged patient safety and experience as their
number one priority supported by our corporate strategy. Our continued commitment to
improving the quality of our care and service quality for our patients remains our number
one priority. It is prevalent at every level of our organisation and is generating excellent
performance results. Our Board of Directors receive and discuss quality, performance and finance at every Board
meeting. We use our Patient Safety and Quality Standards (PS & QS) Committee and
our Audit Committee to assess and review our systems of internal control and to provide
assurance in relation to patient safety, effectiveness of service, quality of patient experience
and to ensure compliance with legal duties and requirements. The Patient Safety and Audit
Committees are each chaired by non-executive directors with recent and relevant experience,
these in turn report directly to the Board of Directors.
The Board of Directors seek assurance on the Trust’s performance at all times and recognise
that there is no better way to do this than by talking to patients and staff. During 20122013, members of the Board of Directors undertook a night-time review of services. These
unannounced visits, at both our hospitals, enabled members of the Board to witness for
themselves how well our staff manage patient care during the out-of-hours period. This
approach of unannounced visits at varied times will continue during 2013-2014.
Quality standards and goals
Values, standards and goals
The Trust greatly values the contributions made by all members of our organisation, to ensure
we can achieve the challenging standards and goals, which we set ourselves in respect of
delivering high quality patient care. The Trust also works closely with commissioners of the
services we provide to set challenging quality targets. Achievement of these standards, goals
and targets form part of the Trust’s four strategic quality aims.
Listening to patients and meeting their needs
We recognise the importance of understanding patients’ needs and reflecting these in our
values and goals.
Our patients want and deserve excellent clinical care delivered with dignity, compassion, and
professionalism and these remain our key quality goals.
Over the last year we have once again spoken with over 1,000 patients. We have spoken to
them in their own homes, in community clinics and in our inpatient and outpatient hospital
wards and departments. We always ask patients how we are doing and what we could do
better.
We understand from patients that great healthcare is defined in the way that we treat
patients, family members, carers and staff. As a result of this we continue to promote our
RESPECT nursing and midwifery strategy, which was developed by staff, patients, governors
and stakeholders.
4
Annual Quality Account 2012-2013
The strategy encompasses the fundamental elements of what we believe underpins great
patient care. These are:
Responsive
Timely
Equipped
Patients
Carers
Staff
Care and
Compassion
Safe and
Secure
Evidence
Based
Person
Centred
Achievements
Unconditional CQC Registration
During 2012-2013 the Trust met all standards required for successful and unconditional
registration with the Care Quality Commission (CQC) for services across all of our
community and hospital services.
5
Annual Quality Account 2012-2013
Finalists for HSJ Awards
We were particularly pleased to be the only trust in the country to win two National Nursing
Times Awards as well as a regional award in 2012:
Winner, 2012 Nursing Times Infection Control Award
A health economy approach to reducing Clostridium difficile supporting care homes to
reduce environmental contamination.
Winner, 2012 Nursing Times Respiratory Nursing Award
Chronic Obstructive Pulmonary Disease (COPD) prognostic index to facilitate end of life
discussions in primary care; listening to patients.
We also won the regional award in 2012 for:
Winner, Regional Bright Ideas Award Homeward orthopaedic team
Patients who identify a problem with a hip
replacement will receive a telephone call and
advice or an outpatient’s appointment if
clinically appropriate.
Governance Ratings
All NHS Foundation Trusts are subject to assessment by Monitor against their compliance
framework. During 2012-13 we continued to achieve high outcomes for our standards of
clinical care; however the Clostridium difficile target remained a significant challenge and we
did not achieve this. Section 3 describes actions we have taken to manage this.
Our positive patient safety culture, actions and behaviours have continued to deliver results by
improving the safety and quality of care we deliver. Working in the spirit of shared learning,
by communicating with our colleagues and stakeholders, the benefits of this work have been
recognised nationally and internationally. Several of our clinicians and clinical teams have been
featured in journals, conferences, or won prestigious awards over the last year.
6
Annual Quality Account 2012-2013
Introduction to Parts 2 and 3 of our Quality Account
Part 2 of our Quality Account indicates our priorities for the future and Part 3 demonstrates
and reviews our performance over the past year. This Quality Account allows us to
demonstrate our commitment to continuous, evidence-based quality improvement; to draw
your attention to the standards achieved and the progress we have made; and to describe
the approach we intend to continue improving our services to patients. It enables you the
opportunity to assess the quality of our performance across the healthcare services we offer.
Chief Executive Alan Foster MBE visits the Single Point of Access team. Alan is pictured with (left to right)
Amanda Dunn, Tracy Robinson, Carole Storm, Angie Hewitson and (front left to right) Ann Wise and Sam Wharam
The areas we have chosen as our quality improvement targets for 2013-2014 have once
again been set following consultation with our Council of Governors, local health scrutiny
committees, local involvement networks, healthcare user group, our commissioners and
importantly, by talking to staff, patients and carers.
Progress described within this document is based on data and evidence collected locally and
nationally, much of which is presented as part of our performance framework each month
and in our public board meetings, Council of Governors meetings and to our commissioners.
To the best of my knowledge the information given in this document is accurate.
Alan Foster MBE
Chief Executive
7
Annual Quality Account 2012-2013
Part 2A: The 2012-2013 quality improvement priorities
In our 2011-2012 Quality Account, we identified a number of quality improvement priorities
that patients, staff and stakeholders agreed we should focus on over the last year:
Priority 1, Patient safety: reduce deaths and prevent deterioration;
Priority 2, Effectiveness of Care: clinical documentation and communication;
Priority 3, Patient experience: care with compassion.
Our progress against the above and the action plans for each of them have been regularly
monitored via key quality committees, the Board of Directors and the Council of Governors.
Progress is described in this section for each of the 2013 priorities.
The outcomes reported in Part 3A are those that were requested and agreed with
external and internal stakeholders during consultation. We would like to thank our
stakeholders for their continued engagement and involvement in not only setting our quality
priorities but also in reviewing progress during the year.
We would like to acknowledge the hard work and commitment of our staff, both clinical
and non-clinical across all healthcare settings. It is their hard work and dedication to putting
patients first that delivers positive results.
Priority 1 patient safety: reducing mortality
In 2008 the Trust, in partnership with external and internal stakeholders agreed that its first
priority should be to reduce mortality. Through our quality strategy, we set out a five year
plan to achieve this. Patient safety remains the first priority of every member of staff from
ward to board.
Our first patient safety priority identified by external and internal stakeholders as well as
well as our staff was to reduce the number of patients that die in our hospitals. This year
we continued to reduce opportunity for avoidable deterioration at home or in hospital.
Some of our ambitions for 2012-2013 were more complex than anticipated and took us
longer than expected to achieve. For example, developing an early warning score for use by
community nurses took longer than expected because we had to develop and test a new
product before we could introduce it for use by community staff.
Our community team developed a process for identifying patients at risk of deterioration
at home through the use of Telehealth. During the last year we have collected data which
identifies the contribution that this assistive technology makes, in conjunction with skilled
clinical support, to safely care for patients in their own home.
Why/How we chose this as a priority:
Reducing mortality has been a key priority since 2008. We have been reporting on our
progress to external and internal stakeholders, for example to our commissioners, Council
of Governors, to health scrutiny committees and to local involvement networks. During the
consultation, Priority 1, everyone agreed that this must remain our number one priority.
Stakeholders also asked that we develop a process that can be used in patients' own homes
to prevent escalation to hospital for patients with chronic conditions where appropriate.
8
Annual Quality Account 2012-2013
What we said we would do: Reduce deaths and prevent deterioration
Monitoring patient safety; mortality
Rationale: Staff, patients and key stakeholders agreed that reducing mortality ratio should
continue to be our first patient safety objective.
Hospital Healthcare
Overview of how we
said we would do it
Overview of how we said
we would measure it
Overview of how we
said we would report it
How did we do?
• We will undertake
monthly mortality
reviews using the
global trigger tool.
• Use of the Dr Foster
mortality database which
predicts the number
of deaths that should
be expected in our
hospital based upon local
demographic information
and case mix.
• Dr Foster mortality
data to be presented at
every public meeting of
the Board of Directors.
• Reported at every
Public Board of
Directors meetings.
✔
• Reported at
every Council
of Governors
meeting.
✔
• Over 961 sets of
observation charts
reviewed.
✔
• Reported HSMR,
SHMI and Crude
Mortality Rates.
✔
• Audits of Early
Warning Score
(EWS) undertaken.
✔
• Senior doctors and
nurses will continue
to review clinical
incidents on a
weekly basis.
• Mortality data to
be presented to the
Council of Governors
on a quarterly basis.
• Monitoring Dr Foster
data every month to
track our progress
against our target.
• Review the CHKS data
supplied by the North
East Quality Observatory
System to benchmark
mortality in our Trust
against other Trusts in
the North East.
• Monitor management of
the deteriorating patient
by reviewing observation
charts on at least 50
patients every month.
As can be seen below, the outcome of Priority 1 was achieved. The following evidence
provides more detail to demonstrate / support these trends.
The Trust continues to monitor all mortality data including raw mortality data (all actual
deaths) weekly as well as looking at monthly and quarterly trends. This data is benchmarked
regionally and the overall trend remains positive.
Dr Foster reporting period of February 2012 to January 2013 (rolling 12-month period of
latest data) - Mortality (in-hospital) measures the Trust as 103.70 against the national
average of 100.
The following chart details the reporting period of February 2011 to January 2012 against the
most recent time period available in Dr Foster (February 2012 to January 2013).
Mortality Benchmarking against peer group
120
100
80
60
40
20
0
Northumbria
Healthcare NHS
Foundation
Trust
South Tees
North Tees and
Hospitals NHS Hartlepool NHS
Foundation
Foundation
Trust
Trust
Feb11-Jan12 Relative Risk
Gateshead
Health NHS
Foundation
Trust
South Tyneside County Durham City Hospitals The Newcastle
Sunderland
Upon Tyne
NHS Foundation & Darlington
NHS Foundation NHS Foundation Hospitals NHS
Trust
Trust
Trust
Foundation Trust
Feb12-Jan13 Relative Risk
National Avergae
NB: Data obtained from Dr Foster
9
Annual Quality Account 2012-2013
Dr Foster reporting period of February 2012 to January 2013 (rolling 12 month period of
latest data) – Hospital Standardised Mortality Ratio (HSMR) measures the Trust as 102.72
against a national mean of 100.
The following chart details the reporting period of February 2011 to January 2012 against the
most recent time period available in Dr Foster (February 2012 to January 2013).
HSMR Benchmarking against peer group
120
100
80
60
40
20
0
South Tees
Hospitals NHS
Foundation
Trust
Northumbria North Tees and
Healthcare NHS Hartlepool NHS
Foundation
Foundation
Trust
Trust
Feb11-Jan12 Relative Risk
Gateshead
Health NHS
Foundation
Trust
County Durham City Hospitals South Tyneside The Newcastle
& Darlington
Sunderland
Upon Tyne
NHS Foundation
NHS Foundation NHS Foundation
Hospitals NHS
Trust
Trust
Trust
Foundation Trust
Feb12-Jan13 Relative Risk
National Avergae
NB: Data obtained from Dr Foster
Hospital Standardised Mortality Ratio (HSMR)
The following HSMR graph demonstrates the Trusts Relative risk throughout the reporting
period (February 2012 to January 2013) (rolling 12 month period of latest data). The Trusts
yearly average for Relative Risk is currently 103.00, which is slightly above the national
average of 100.
The following chart shows the Trusts historical position with the most upto date
available data.
Relative Risk
150
125
100
75
50
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
2011/12
2012/13
Trend (Month)
Relative Risk
*Data taken from Dr Foster
10
Annual Quality Account 2012-2013
National Average
Hospital healthcare - evidence in practice
Reduced cardiac arrests
A cardiac arrest is what happens when a patient’s heart stops.
We believe (and the evidence supports) that this reduction is linked to a reduction in the
number of patients that deteriorate whilst in our care.
During 2012-13 the Trust has experienced unprecedented numbers of very sick patients being
admitted to hospital. Although this inevitably results in more patients having a cardiac arrest, we
are pleased that we are sustaining very low numbers of patients who show signs of deterioration
prior to their cardiac arrest, which is demonstrated in the tables below.
Cardiac Arrests
Deteriorating Physiology
Apr - Jun
2012
Jul - Sept
2012
Oct - Dec
2012
Jan - Mar
2013
Total
34
21
31
34
120
2
5
6
12
25
Number of cardiac arrests
Deteriorating physiology prior to cardiac arrest
There were 120 cardiac arrests during this period, 25 had signs of deteriorating physiology
prior to cardiac arrest, which equates to 20.83%.
A full Root Cause Analysis (RCA) has been undertaken in relation these cases to ensure that
there was a clear understanding of events that led up to cardiac arrest.
Multi-professional teams review RCAs from all patients who have sustained cardiac arrests.
Cardiac Arrest Comparisons
45
40
35
30
25
20
15
10
5
0
Apr - Jun
Jul - Sept
2010-2011
Quarter/Year
Oct - Dec
2011-2012
Jan - Mar
2012-2013
Apr-Jun
Jul-Sep
Oct-Dec
Jan-Mar
Totals
2010 - 2011
22
28
38
41
129
2011 - 2012
29
12
28
22
91
2012 - 2013
34
21
31
34
120
11
Annual Quality Account 2012-2013
Infection Control
Rationale: Key stakeholders asked us to report on clostridium difficile (C diff) because we did
not achieve a reduction in 2012-2013. Trust commissioners and clinicians also asked that we
report on e-coli infections.
Hospital Healthcare
Overview of how we
said we would do it
Overview of how we said
we would measure it
Overview of how we
said we would report it
How did we do?
• Staff training will
be monitored.
• We will monitor rates of
C diff.
• The number of e-coli
infections will be
reported.
• Reported at every
Public Board of
Directors meetings.
✔
• The number of
e-coli infections
will continue to be
reported.
• At every public
board and council of
governors meeting.
• At quarterly IPC
committee.
• Reported at
every Council
of Governors
meeting.
✔
• Discussed in
detail at Audit
Committee
and Directorate
meetings.
✔
• Reported in detail
to Monitor.
✔
• Two external
reviews undertaken
at the Trust
request.
✔
• Unannounced
Prevention
Protection
Control practices
undertaken.
✔
• Did not achieve
the 2012-13 C diff
target of 44 cases.
✘
• Every hospital
acquired C diff and
e-coli infection will
be investigated to
establish cause and
actions required.
• We will report any
trends and actions.
• At meetings with our
commissioners.
Clostridium Difficile (C diff)
During 2012-2013 we did not achieve our C diff target. We continued to work hard to
control and reduce opportunity for infections to spread when we treat people in our clinical
premises or in their own homes. There is no one way in which C diff can be eliminated
but a consistent approach across the important areas of cleanliness of the environment;
appropriate antibiotic prescribing and strict hygiene at the point of care are vigorously
pursued. We continue to invest in new equipment, which is easier to clean, and which is
less likely to harbour infections. An independent review of infection prevention and control policy and practice in the Trust
was carried out in August 2012, and recommendations were made to further enhance
antibiotic prescribing, stewardship, and audit of time to isolate. An action plan was
developed in response to the review, and has been presented to both the Board of Directors
and Council of Governors.
Our hygienists continue with a programme of deep cleaning and fogging with hydrogen
peroxide, which has been found to kill the spores responsible for people getting C diff. The
work has also been extended to our local care homes as part of a project to reduce recurrent
infections and improve patient experience. The Trust won a Nursing Times award for this
innovative and collaborative work.
The directors responsible for infection prevention and control and for estates and facilities,
undertake regular walkabouts to provide support to staff and assurance to the Board of
Directors that any environmental issues are dealt with speedily and effectively.
12
The Trust has undertaken a comprehensive review in relation to C diff. Whilst recognising that
number of C diff reported by the Trust is higher than other Trusts, it is of interest to note that
it also sends a higher proportion of samples for testing.
Annual Quality Account 2012-2013
The national Health Protection Agency inclusion criteria for reporting C. difficile infections is
as follows:
Any of the following defines a C. difficile infection case in patients aged 2 years and above
and must be reported to the HPA:
1. Diarrhoeal stools (Bristol Stool types 5-7) where the specimen is C. difficile toxin positive;
2. Toxic megacolon or ileostomy where the specimen is C. difficile toxin positive;
3. Pseudomembranous colitis revealed by lower gastro-intestinal endoscopy or Computed
Tomography;
4. Colonic histopathology characteristic of C. difficile infection (with or without diarrhoea or
toxin detection) on a specimen obtained during endoscopy or colectomy;
5. Faecal specimens collected post-mortem where the specimen is C. difficile toxin positive
or tissue specimens collected post-mortem where pseudomembranou .
How did we do?
In 2012-2013, we had a challenging C diff target set by our commissioners, which we did
not achieve. Over the last few months of the year we were able to bring our rate down,
however, the larger numbers in the second quarter of the year resulted in our breaching the
end of year target. The following table identifies the numbers of hospital acquired C diff cases
reported by the Trust against the target for that period. The table also identifies the number
of community acquired cases of clostridium difficile reported by our laboratory.
Quarter
Q1
Q2
Q3
Q4
Target for hospital acquired cases
15
15
8
6
Number of hospital acquired cases
11
23
13
14
Number of community acquired cases (acquired in people’s own homes)
17
34
23
21
North East Trusts stool specimens examined and tested for C diff.
Trust 1
Total No. stool specimens examined
C diff toxin tests
% of C. diff toxin tests V examined
Trust 2
Trust 3
North
Tees and
Hartlepool
NHS
Foundation
Trust
Trust 5
Trust 6
2011
2012
2012
2012
2012
2013
Apr
-Jun
Jul Sept
Oct
-Dec
Jan Mar
Apr
-Jun
Jul Sept
Oct
-Dec
Jan Mar
1,536
1,666
1,554
1,609
1,582
1,718
1,730
918
842
872
904
896
857
969
59.77
50.54
56.11
56.18
56.64
49.88
56.01
Total No. stool specimens examined
3,329
4,913
6,848
5,664
5,530
5,342
5,563
1,389
1,307
1,829
1,539
1,547
1,276
1,602
% of C. diff toxin tests V examined
41.72
26.60
26.71
27.17
27.97
23.89
28.80
Total No. stool specimens examined
1,299
1,419
1,269
1,263
1,230
1,237
1,518
C diff toxin tests
110
102
91
101
109
91
92
% of C. diff toxin tests V examined
8.47
7.19
7.17
8.00
8.86
7.36
6.06
Total No. stool specimens examined
2,030
2,167
2,218
2,658
2,386
2,627
2,664
C diff toxin tests
1,035
1,053
1,184
1,312
1,108
1,395
1,349
% of C. diff toxin tests V examined
50.99
48.59
53.38
49.36
46.44
53.10
50.64
Total No. stool specimens examined
3,003
3,056
2,581
2,834
2,638
2,659
2,862
C diff toxin tests
1,613
1,501
1,228
1,344
1,268
1,030
1,271
% of C. diff toxin tests V examined
53.71
49.12
47.58
47.42
48.07
38.74
44.41
Total No. stool specimens examined
2,260
2,714
2,358
2,626
3,169
3,132
3,241
706
666
612
741
737
585
664
% of C. diff toxin tests V examined
31.24
24.54
25.95
28.22
23.26
18.68
20.49
Total No. stool specimens examined
1,895
2,048
1,927
2,109
1,973
No Data
No Data
270
317
270
253
255
No Data
No Data
C diff toxin tests
Trust 8
2011
C diff toxin tests
C diff toxin tests
Trust 7
2011
% of C. diff toxin tests V examined
14.25
15.48
14.01
12.00
12.92
-
-
Total No. stool specimens examined
4,059
5,466
3,746
4,314
4,224
3,792
4,472
C diff toxin tests
1,099
1,068
1,149
1,339
1,498
1,210
1,526
% of C. diff toxin tests V examined
27.08
19.54
30.67
31.04
35.46
31.91
34.12
To note: Quarter 4 (Jan-March 2013) data not available at time of print. Data obtained from Health Care Acquired
Infection (HCAI) data capture system administered by Public Health England.
Annual Quality Account 2012-2013
13
The following table shows the number of C diff cases that have been confirmed
each month for each North East Trust.
2012/13
Apr
May
Jun
Q1
Quarter
Jul
Aug
Total
Sep
Q2
Quarter
Oct
Total
Nov
Dec
Q3
Quarter
Jan
Total
Feb
Mar
Q4
Quarter
Year
Total
Total
Trust 1
1
3
6
10
8
3
3
14
4
8
6
18
0
7
8
15
57
Trust 2
5
5
8
18
6
4
4
14
8
6
3
17
3
4
9
16
65
Trust 3
2
1
2
5
3
0
1
4
3
6
2
11
1
0
5
6
26
North
Tees and
Hartlepool
NHS
Foundation
Trust
0
5
6
11
9
9
5
23
3
6
4
13
7
5
2
14
61
Trust 5
6
8
8
22
0
2
8
10
6
4
3
13
1
2
5
8
53
Trust 6
3
6
7
16
5
1
4
10
2
8
4
14
5
0
3
8
48
Trust 7
1
0
1
2
2
0
1
3
1
1
0
2
0
0
0
0
7
Trust 8
7
8
6
21
7
8
6
21
7
6
3
16
4
8
4
16
74
Monitor, our regulator has reviewed actions taken by the Trust and (at the time of writing)
is also satisfied that the Trust has done and continues to do all that we can to reduce
opportunity for patients to acquire C diff whilst in hospital. Monitor continues to review
the position.
The trend in hospital acquired C diff over the last six years can be seen in the following table:
Year
2007-2008
Clostridium difficile
210
2008-2009
158
2009-2010
2010-2011
136
53
2011-2012
2012-2013
68
61
The numbers of E-coli reported across the community and our hospitals during the year are
presented below. When compared against the 2011-12 figures, it is clear that there needs to
be continued engagement with Primary Care.
Hospital acquired E-coli
Community acquired E-coli
Apr 11 to Mar 12
Apr 12 to Dec 13
41
31
149
194
Monitoring patient safety
Rationale: stakeholders were pleased that we managed to develop an early warning status
tool in the community. They wanted to understand the impact of this over a period of time.
Community Healthcare
Overview of how we
said we would do it
Overview of how we said
we would measure it
Overview of how we
said we would report it
How did we do?
• We will roll out
use of the new
community early
warning status
allied to Telehealth
status tool to more
areas.
• Monitor admissions to
hospital.
• Quarterly reports to
the IPNMB.
• Quarterly Reports
to IPNMB.
✔
• Number of alerts
monitored.
✔
• Number of
red alerts from
patients on
Telehealth use
monitored.
✔
• Number of
red alerts from
patients managed
at home.
✔
• Number of
patients with red
alerts admitted to
hospital.
✔
14
Annual Quality Account 2012-2013
Community healthcare - evidence in practice
Development and use of bespoke Telehealth early warning status (EWS) tool for
use in community services. We could find no nationally developed early warning status for
use in community settings. Our community staff therefore tested the hospital EWS tool for
use in the community. The hospital EWS did not work in the community, therefore some staff
developed and tested their own system linked to Telehealth.
The community EWS track and trigger tool measures patient blood pressure, temperature,
pulse and oxygen levels and a trigger (of worsening condition) results in a speedy review
of medication and care. The system supports real-time flow of information from patient to
clinical staff, supporting continuous evaluation of care needs, risks and appropriately
timed interventions. We believe that the system designed by staff will help avoid crisis or
deterioration resulting in a need for unscheduled care (unplanned intervention or admission
to hospital).
The key measurable benefits to patients using this tool include:
•Supported early discharge;
•Improved confidence because patients know that their condition is being closely monitored;
•Rapid response to any change in worsening condition;
•Improved clinical risk management for a group of patients known to a service;
•Fewer unplanned admissions or readmissions to hospital;
•Convenience and comfort of being monitored at home.
The Telehealth EWS track and trigger tool was implemented in December 2011, with baseline
outcomes being measured and reported in the 2012-2013 Quality Account and Report.
Introduction and early success of this ground-breaking work has resulted in our staff aim of
developing a virtual ward in the community being achieved.
Yes
2
192
Yes
➜
N/A
359
Yes
➜
58
408
Yes
➜
30
288
Yes
➜
15
191
Yes
➜
119
303
Yes
➜
68
302
Yes
➜
44
244
Yes
49
246
Yes
➜
9
263
Yes
➜
188
26
25
3
June
22
22
2
July
19
19
0
August
64
➜
3
May
64
58
September
45
45
30
October
39
39
15
November
28
28
119
December
0
N/A
68
January
0
➜
N/A
44
February
7
➜
➜
3
7
49
March
9
➜
Yes
23
➜
201
23
➜
3
April
➜
Q4
Green
alerts
➜
Q3
Number
managed
at home
➜
Q2
Amber
alerts
➜
Q1
Number
managed
at home
➜
Red
alerts
➜
Summary of community EWS alerts:
9
38
Was the response
within 2 hours?
15
Annual Quality Account 2012-2013
Telehealth Case Study
The Trust’s telehealth services when used in the right setting, with the right support continues
to improve the lives of people with complex long-term conditions, and supports them to
manage their health and care. The following case study provided by the specialist heart failure
nurse gives insight into both patient and clinician experience of using telehealth.
David is a 43 year old gentleman who was admitted to hospital in March 2012. During his
stay he was diagnosed with cardiomyopathy and heart failure (cardiomyopathy refers to heart
muscle disease). I first met David the following day and found him to be very anxious and
distressed regarding his diagnosis. I spent a lengthy visit giving explanations and reassurances
regarding his forthcoming management. I called back to see him as agreed and found that
he had been back into hospital for an overnight stay after experiencing breathlessness and
palpitations. All of his cardiac investigations were stable. In the subsequent days David
contacted me about four times each day mainly needing reassurance. He also attended
the One-Life Centre (minor injuries unit) on two other occasions.
A telehealth unit was installed later that month and David was taught how to use it and how
it would be checked. In the first two days he had two red flags due to bradycardia (slow heart
rate). David had the telehealth service in place for six weeks. However, after four weeks he felt
much better and did not need it. David was able to go out every day walking and is looking
forward to returning to work.
David had no further admissions to hospital or the One-Life Centre and has since returned to
full-time employment with routine six monthly checks from the heart failure team.
David stated that using the system had been a very positive experience and that it allowed him
to feel assured that he was being checked regularly and that any problems would be acted
upon quickly.
Community nursing team in Billingham.
16
Annual Quality Account 2012-2013
Priority 2 effectiveness of care; clinical documentation and communication
Patients and stakeholders said that they would like us to listen to patients and to provide
opportunities for concerns to be heard and acted on in a timely way.
In the past year there have been a number of high-profile reports that have drawn attention
to examples of poor standards of healthcare. One such report is the Mid-Staffordshire Inquiry,
outlining the poor provision in attending to patients’ needs. A copy of the Francis Report can
be found on:
www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/
digitalasset/dh_113447.pdf
The most recent report which includes 290 recommendations can be found at:
www.midstaffspublicinquiry.com/report
In order to challenge and prevent poor practice, North Tees and Hartlepool NHS Foundation
Trust have implemented Intentional Rounding.
Intentional Rounding provides an opportunity for our nurses to pick up and address any
issues or concerns our patients and visitors have in a timely way.
Through communicating with patients and relatives, Intentional Rounding should provide
confidence and reassurance in a calm and orderly environment. This is in line with both our
Trust RESPECT strategy, and the national 6c’s nursing and midwifery strategy.
Patient Stories
As part of the Trust commitment to listening to our patients, a number of DVDs have been
undertaken and subsequently shared with doctors and nurses during formal and informal
teaching sessions. These stories are told by patients who have had experiences they wish
to share. As part of this listening experience we have also undertaken a number of written
patient stories for those patients who do not want to appear in a DVD but still want their
story told.
17
Annual Quality Account 2012-2013
What we said we would do:
Improve quality of documentation and communication
Communication:
Rationale: stakeholders said they would like us to continue to listen to patients and provide
improved opportunities for concerns to be heard and acted on. Staff believe that Intentional
Rounding will provide an opportunity to understand and act on patient needs in a timely way
that is meaningful to them.
Hospital Healthcare
Overview of how we
said we would do it
Overview of how we said
we would measure it
Overview of how we
said we would report it
How did we do?
• We will roll
out Intentional
Rounding to listen
to what patients
and relatives
have to say about
standards of care
and experience.
• We will monitor what
we are told and take
actions to address any
concerns.
• Ward/department
leaders will feedback
daily results of
Intentional Rounding
to their staff.
• Although we have
implemented
Intentional
Rounding across
the Trust, we
are unable to
demonstrate daily
feedback happens
in all areas.
✘
• Themes of
compliments and
concerns have
been reported
to IPNMB, at
directorate
meetings and
at Trust Director
Group (TDG).
✔
• There was no
method of
capturing this data
therefore the Trust
has developed a
way of doing this.
✔
• We continue to
report learning
from complaints
and incident trends
locally, regionally
and nationally to
PS & QS.
✔
• We will continue to
ask patients about
their experience of
clinical care and
experience during
our PEQS (patient
experience and
quality standards)
reviews.
• We will record the
results of PEQS reviews.
• We will monitor and
report the impact of this
on complaints relating
to nursing.
• Themes of
compliments and
concerns will be
reported to the
Integrated Nursing
and Midwifery Board
six-monthly.
• Complaints
relating to nursing
communication will
be reported to the
Integrated Nursing
and Midwifery Board
six-monthly.
• Complaints and
Patient Advice and
Liaison (PALS) trends
are reported quarterly
to the Patient Safety
and Quality Standards
Committee.
Hospital healthcare – evidence in practice
Intentional Rounding was introduced to enhance the quality of communication and
emotional support to patients and carers. It was initially introduced into Maternity services
with excellent results; within three months complaints in relation to Midwifery care had
reduced by 55%. Intentional Rounding was subsequently rolled out to all inpatient areas.
This is not yet firmly embedded but there are a number of good practices seen, including
the fact that a number of clinical areas document Intentional Rounding in the patients
contemporaneous notes.
The Board of Directors have commenced regular unannounced reviews of care, which is a
good example of corporate Intentional Rounding.
Our continued success with the PEQS reviews provides additional opportunity for senior
nurses to undertake adhoc Intentional Rounding.
Over the year, during our scheduled PEQS reviews, our senior nurses, Governors and Directors
visited 224 wards and departments in our hospitals, speaking to 961 patients and/or relatives
as well as reviewing standards in community clinics and in patients own homes.
18
Annual Quality Account 2012-2013
The following table provides data relating to 2011/2012 and 2012/2013 visits:
2012-13
Wards Visited
209
224
Patients Seen
777
961
Yr on Yr
Comparison
➜ ➜
2011-12
15
184
In 2012 the Trust developed a comprehensive PEQS database, to record all reviews and
enable detailed analysis and provide trends for each area and ward. This enables them to
monitor and share good practice and provide support where needed.
Reports from PEQS reviews are provided to both the Board of Directors and the Council of
Governors.
The Board of Directors have visited the hospitals at night to review standards of care and to
derive assurance that standards remain high no matter what time or day patients are treated
in our hospitals. Commissioners have also undertaken an unannounced night time review
with positive feedback.
The following table reflects the comparisons between 2011-12 and 2012-13 PEQS data for
the three key areas in respect of the Trust's hospitals:
2012-13
(%)
First Impressions
91
85
Nursing Evidence
90
87
Patient Experience
98
96
Yr on Yr
Comparison (%)
➜ ➜ ➜
2011-12
(%)
6
3
2
Community PEQS
The following table reflects the comparisons between 2011-12 and 2012-13 for the
Community PEQS Scores.
In 2012-13 there were 48 patient homes visited.
2012-13
(%)
First Impressions
98
100
Nursing Evidence
77
90
Patient Experience
95
100
Yr on Yr
Comparison (%)
➜ ➜ ➜
2011-12
(%)
2
13
5
19
Annual Quality Account 2012-2013
Detail of the impact of the improvements linked to Priority 2 are demonstrated further below:
Hospital healthcare – evidence in practice
The way we captured information within the complaints department meant that we were
unable to disaggregate nursing complaints. Therefore a nursing dashboard has been
developed to support the capture and reporting of this information more effectively.
Overall patients tell us that they are satisfied with communication
In 2012-13 our Governors and non-executive board members spoke to 961 patients to
ask amongst other things, whether our healthcare professionals communicate well with
them. They were asked if they understood what the plan of care is and whether they have
been involved in decisions about them with staff communicating in a way they understand,
using language they understand. Patients and relatives were asked if they knew what their
medications are for and if they knew what tests they are having and why. They were also
asked if our staff treat them with dignity and respect, with kindness and compassion and
whether or not they would recommend our Trust. 94.46% of the 961 patients spoken to
reported that they were satisfied with quality of communication and 97.89% reported that
they were always treated with dignity and respect. 97.19% of patients interviewed reported
that they would recommend the ward or department they were being treated on.
These questions continue to be asked on a regular basis and whilst recognising that we don’t
get it right every time, we have learned from these reviews as well as from the national
survey that patients are satisfied with the following aspects of communication:
•We are involving people in decisions about their care;
•People can find someone to talk to about their worries and fears;
•Patients believe they are given enough privacy when discussing their condition or
treatment;
•Although we score well when compared to Trusts nationally in relation to telling people
about the medication side-effects to watch out for when they go home, there are still
improvements we can make;
•Our patients gave us a good score when they were asked if they knew who to contact if
they were worried about their condition.
The National Cancer Patient Survey reported that 72% of patients felt they could discuss
worries or fears with staff during visits, placing us in the top 20% nationally.
We were also in the top 20% nationally in giving the patient enough emotional support (84%
up from 77% in 2010).
Trends over three years can be seen in the table below (data taken from the latest national
inpatient survey used for CQUIN).
20
Annual Quality Account 2012-2013
82.7
82.6
63.9
71.0
➜
79.3
59.1
➜ ➜
Were you given enough privacy when
discussing your condition or treatment?
➜
59.9
73.6
2012
➜ ➜
Did you find someone to talk to about worries
and fears?
71.2
2011
➜
68
2010
➜
Were you as involved as you wanted to be in
decisions about your care and treatment?
2009
➜
Question
84.00
59.0
Complaints and Compliments
From Q3 2011/2012 there were 584 complaints of which 48 were related to
communication across all staff groups and services in hospital and the community.
In relation to compliments there were 7,985 for the same period.
Complaints
Quarter
Q3 11-12
Q4 11-12
Q1 12-13
Q2 12-13
Q3 12-13
Q4 12-13
91
97
111
91
102
92
Q3 11-12
Q4 11-12
Q1 12-13
Q2 12-13
Q3 12-13
Q4 12-13
1,552
1,455
756
1,157
1,610
1,855
Total
Compliments
Quarter
Total
For regional and national benchmarking see section 3.
Communication: expand deployment of tough books (mobile working)
Rationale: tough books were introduced in 2011-2012, subsequent successful bids will
enable the Trust to double the number in use in 2013
Community Healthcare
Overview of how we
said we would do it
Overview of how we said
we would measure it
Overview of how we
said we would report it
How did we do?
• Training and
deployment of
initial 40 tough
books to be
completed within
first three-months
of 2012 (AprilJune).
• The number of units in
use will be reported.
• Progress will be
reported twice yearly
to the Patient Safety
and Quality Standards
Group.
• Progress reported
to PS & QS.
✔
• Progress reported
quarterly to
IPNMB.
✔
• Progress reported
to Trust executive
group.
✔
• 154 additional units
to be deployed
during the
remainder of 20122013.
• The impact of mobile
working (tough books)
on admission to hospital
rates and on length
of stay in hospital of
patients with chronic
conditions will be
monitored.
• The Trust executive
management team
will receive a progress
report twice a year.
Community healthcare – evidence in practice
The use of the tough books allows staff to electronically and contemporaneously update
patient information at the point of care, resulting in timely and accurate documentation and
clinical decision-making. This improved access to high quality information has improved staff
confidence when working across teams.
339 tough books are currently in use across the directorate. This includes 145 (50 Phase 1
and 95 Phase 2) provided through the Department of Health (DH) pilot, 40 procured through
reablement funding and 154 funded locally. There has been further funding approved and
we are commencing the procurement of additional mobile devices.
The Trust has been involved with the National Mobile Health Worker Project which has
recently produced its final report. A number of key improvements were evident during the
ongoing evaluation including:
Phase 1 (50 units)
•Contacts with patients increased by 39% throughout the course of the pilot and showed a
consistent increase through the life of the project;
•Time spent with patients has increased by 45%;
•The report shows an increased efficiency around travel as there has been a smaller increase
in the number of journeys when correlated to the increased number of contacts.
Annual Quality Account 2012-2013
21
Phase 2 (95 units)
•Contacts with patients increased by 33% throughout the course of the pilot and showed a
consistent increase through the life of the project;
•Time spent on journeys decreased by 5%.
All the staff have immediate access to corporate and clinical policies at the point of contact
because they are immediately available on the tough-book.
The directorate is now undertaking some work with specific teams to enable a standardised
approach to the use of the system and the technology.
Priority 3 Patient Experience
Dementia
Rationale: as the population becomes older, dementia is becoming more common.
Dementia is a priority for stakeholders, commissioners and staff alike.
Hospital Healthcare
Overview of how we
said we would do it
Overview of how we said
we would measure it
Overview of how we
said we would report it
How did we do?
• We will conduct
an initial dementia
screen on all
patients aged 65
and over.
• We will undertake a
prevalence study on a
quarterly basis.
• Quarterly to the
Integrated Nursing and
Midwifery Board.
• Progress reported
to PS & QS.
✔
• Quarterly to our
commissioners.
• Progress reported
quarterly to
IPNMB.
✔
• Progress reported
to Trust executive
group.
✔
• Where indicated,
we will carry out
abbreviated mental
health tests on
patients that fit the
dementia criteria.
• If required we will
refer patients for
specialist review.
Dementia can have a devastating impact on both the patient and those caring for them. Year
on year the total number of people with a confirmed dementia diagnosis is increasing. There
are currently over 14,000 people with dementia across County Durham and Darlington, and
Tees Acute services area. NHS Hartlepool/Stockton and Tees Clinical Commissioning Group
(CCG) has the highest projected increase of dementia by 2025 across the North East (NEQOS,
North East Quality Observatory System 2012).
Ensuring patients with dementia receive high quality care from staff who are knowledgeable
and skilled remains a key objective for the Trust and key stakeholders.
Progress against the outcomes agreed with stakeholders last year are included within this
section.
A prevalence study (snapshot survey over one day across all clinical inpatient departments)
has been undertaken monthly from September 2012, and results are shown on the month
data collection table that follows:
22
Annual Quality Account 2012-2013
The prevalence study identified a number of measures which are reported in the table below:
Dementia Screening - Monthly Data Collection 2012-13
Question
Sept
Oct
Nov
Dec
Jan
Feb
Mar
a
Number of patients 75 and above
admitted as emergency inpatients,
reported as having been asked the
dementia case finding question
within 72 hours of admission to
hospital or who have a clinical
diagnosis of delirium on initial
assessment or known diagnosis of
dementia.
349
353
386
433
423
390
437
b
Number of patients aged 75 and
above, admitted as emergency
inpatients, minus exclusions.
374
367
412
433
423
390
437
c
% of all patients aged 75 and
above admitted as emergency
inpatients who are asked the
dementia case finding question
within 72 hours of admission or
who have a clinical diagnosis of
delirium on initial assessment or
known diagnosis of dementia.
93.30%
96.20%
93.70%
100%
100%
100%
100%
d
Number of admissions of patients
aged 75 and above admitted as
emergency, inpatients who have
scored positively on the case
finding question or who have
a clinical diagnosis of delirium
reported as having had a dementia
diagnostic assessment including
investigations.
217
58
72
57
112
117
136
e
Number of patients aged 75 and
above admitted as emergency
inpatients who have scored
positively on the case finding
question or who have a clinical
diagnosis of delirium.
217
58
75
57
112
117
136
f
% of all patients aged 75 and
above admitted as emergency
inpatients who have scored
positively on the case finding
question, or who have a clinical
diagnosis of delirium and who
do not fall into the exemption
categories reported as having had
a dementia diagnostic assessment
including investigations.
100%
100%
96%
100%
100%
100%
100%
g
Number of all patients aged
75 and above admitted as an
emergency inpatient who have
had a diagnostic assessment
(in whom the outcome is either
positive or inconclusive) who are
referred for further diagnostic
advice/follow up.
21
19
10
14
28
23
41
h
Number of patients aged 75
and above who were admitted
as an emergency inpatient
who underwent a diagnostic
assessment (in whom the outcome
is either positive or inconclusive).
21
20
11
14
28
23
41
i
% of all patients aged 75 and
above, admitted as an emergency
inpatient who have had a
diagnostic assessment (in whom
the outcome is either positive or
inconclusive) who are referred for
further diagnostic advice/follow
up.
100%
95.00%
90.90%
100%
100%
100%
100%
23
Annual Quality Account 2012-2013
Dementia
Rationale: district nurses are in a strong position to pick up early signs of dementia.
We will develop a dementia screening tool for use by community adult nurses.
Community Healthcare
Overview of how we
said we would do it
Overview of how we said
we would measure it
Overview of how we
said we would report it
How did we do?
• If the Department
of Health (DH)
recommend
a dementia
test for use by
community nurses,
we will adopt
it and monitor
compliance.
• We will evaluate the
accuracy of the early
warning score by
reviewing the number
of patients requiring
onward referral for
further tests and the
outcome of the tests.
• We will report whether
we have adopted
the national tests or
alternatively, managed
to develop a dementia
early warning score
for use by community
nurses.
• Progress reported
to PS & QS.
✘
• Progress reported
quarterly to
IPNMB.
✘
• Progress reported
to commissioners.
✘
• We will report how
many patients we
use the early warning
scores on, and the
outcome.
• If not, we will
evaluate dementia
screening tools in
other healthcare
sectors.
• We will develop
and test a dementia
early warning score
for district nurses.
The DH has not provided any guidance/recommendations for dementia screening in the
community. This has resulted in an inability to achieve this outcome. The Trust aims to pilot a
community trigger tool for dementia screening from March which we aim to rollout in 2013.
Priority 3 Patient Experience; Discharge arrangements
Discharge Arrangements:
Rationale: quality and monitoring of complex discharge arrangements remains a focus for
patients, commissioners and key stakeholders.
Hospital Healthcare
Overview of how we
said we would do it
Overview of how we said
we would measure it
Overview of how we
said we would report it
How did we do?
• We will develop
improved
communication
processes to GPs.
• We will further enhance
the current discharge
letter format to allow
audit of the quality
of complex discharge
arrangements.
• We will report results
of the baseline audit
data along with any
actions that are agreed
to the Patient Safety
and Quality Standards
Committee at the end
of the reporting year.
• Annual discharge
report to PS & QS.
✔
• Audits of simple
discharge
summaries to
commissioners.
✔
• Audits of complex
discharge
summaries to
commissioners.
✔
• Patient satisfaction
with discharge
arrangements
monitored via
national inpatient
survey.
✔
• Directorates will audit
the quality of discharge
summaries monthly.
• We will collect baseline
data about complex
nursing discharge.
Discharge Arrangements
24
The Trust is required to ensure that at least 95% of electronic discharge summaries are
complete and sent to GPs within 24 hours of discharge. Content must be accurate and of
a high quality to ensure continuity of care and treatment. In collaboration with primary
care colleagues, the Trust has made improvements to the electronic discharge letter, which
includes details of new and discontinued medication and reasons for changes.
Annual Quality Account 2012-2013
There is a section where specific actions recommended to GPs to provide continuing care
and treatment, can be documented. There are also ongoing discussions to include details
regarding palliative care arrangements and recommendations. This should help reduce
inappropriate admissions to hospital so that care can be provided to patients in their own
homes. To monitor the performance, lead clinicians have been identified for each area to
oversee the compliance in their teams.
End of Life Care
Rationale: patients and their carers/families are very vulnerable and can find it difficult to
explain what they want. In 2011, the use of carers diaries has been successful in improving
quality of care and experience. Monitoring the impact of diaries on quality standards results
in better care for patients, better experience for families/carers and better job satisfaction for
staff. Stakeholders asked for this to be included in this year’s priorities.
Hospital Healthcare
Overview of how we
said we would do it
Overview of how we said
we would measure it
Overview of how we
said we would report it
How did we do?
• We will ask families/
carers to score their
perception of the
quality of care in
relation to:
• Ward nurses will review
the diaries during each
visit and respond to the
score to ensure we meet
the needs of the patient
and the families/carers.
• Local results will be fed
back to every ward and
department.
• Progress reported
to PS & QS.
✔
• Corporate data along
with themes, learning
and recommendations
for training will be
reported to the IPNMB
on a quarterly basis.
• Progress reported
quarterly to
IPNMB.
✔
• Progress reported
to commissioners.
✔
• Pain;
• Nausea
(sickness);
• Dyspnoea
(breathlessness);
• Diaries will be audited
corporately and themes
used to inform learning
and training needs.
• Restlessness;
• Nursing care of
patient;
• Nursing care of
families/carers.
The Family’s Voice (previously known as the carers diary) - was rolled out in 2010. At
time of writing, 446 diaries have been given out. 236 have been given between April 2012 –
March 2013, an increase of 43 diaries (22.5%) from the previous reporting year. These results
have demonstrated that a high standard of care continues to be provided. The following
table demonstrates the overall marks afforded to each ward/department across the Trust.
Marks are awarded on a scale of 0 (poor) to 4 (excellent) for each of six key quality
indicators, these being; pain, nausea, breathlessness, restlessness, how the nurse is with
the patient and how the nurse is with the family or carer. The maximum score that can be
achieved is 24.
Ward
Average score
Ward
Average score
1
Ward 32/33 - Ortho Trauma NT
24.00
11
Ward 26 Respiratory NT
21.17
2
Crit Care NT (ITU)
23.75
12
Ward 25 Cardio NT
20.93
3
Ward 2 HP
22.56
13
Ward 24 Elderly Care NT
20.71
4
Ward 30 - Womens Health
Ward 31 - Surg Level 1 Beds NT
22.00
14
Ward 31 - Surg Level 1 Beds NT
20.57
5
Ward 9 HP
21.97
15
Ward 7 HP
20.50
6
Ward 40/41 Stroke Unit NT
21.72
16
Ward 8 - EAU HP
20.00
7
Ward 11 - Acute Ward HP
21.57
17
Short Stay Unit - NT
19.88
8
Ward 42/43 Rehab NT
21.54
18
Ward 27 Acute Medicine NT
19.61
9
Ward 38 - Heamatology NT
21.50
19
Ward 5 HP
19.15
10
Emergency Assessment Unit NT
21.38
20
Ward 28 Mens Health NT
Ward 29 Surg Short Stay NT
15.00
25
Annual Quality Account 2012-2013
Understanding this data helps the Trust to understand how we are doing, and to develop
and target training in end of life care for wards where scores are lower. In 2013 we will, once
again, send our trainers to work with and support staff in developing knowledge and skills to
bring all scores to be equal or exceed the best.
The following table highlights how scores (0 being poor and 4 being excellent with a
maximum score of 24 showing excellence in every aspect of care) and comments made in
one diary helped staff to address issues in a timely way. The improvement in score each
day demonstrates how this important feedback can influence quality of care resulting in a
peaceful death for a patient and the best possible experience for the next of kin.
Day
Pain
Nausea
Calmness
Breathing
Staff/patient
Staff/carer
Total score
One
2
2
2
2
3
2
13/24
Two
3
3
4
3
4
4
20/24
Three
4
4
4
3
4
4
23/24
Four
4
4
4
4
4
4
24/24
When compared to the national VOICES survey the Family’s Voice demonstrated favourable
outcomes especially in relation to pain relief.
VOICES
Pain relief was excellent (Acute Hospital 1)
53.9%
VOICES
Pain relief was excellent (Acute Hospital 2)
23.5%
NT Family’s Voice
Free from pain (all or most of the time - patient days all records)
90.3%
NT Family’s Voice
Free from pain (all or most of the time - last day only)
89.8%
VOICES
Pain relieved completely (Acute Hospital 1)
26.0%
VOICES
Pain relieved completely (Acute Hospital 2)
36.0%
VOICES
Pain relieved completely (Hospice 1)
50.0%
VOICES
Pain relieved completely (Hospice 2)
67.0%
NT Family’s Voice
Free from pain (all of the time - patient days all records)
53.8%
NT Family’s Voice
Free from pain (all of the time - last day only)
63.5%
Senior clinical matron Karen Walker and matron Stuart Harper educate the ward staff on the first World Sepsis Day
26
Annual Quality Account 2012-2013
Comments from the diaries chosen at random:
Ward A ‘found staff very caring and
attentive and willing to answer all my
questions to the best of their ability.’
Ward G ‘Excellent care.’
Ward H ‘Thank you for the care and
attention that was given to my aunt.
Many thanks to the doctors and all the
staff on ward G.’
Ward B ‘Armchairs could be more
comfortable if a little higher.’
Ward I ‘Your staff are a huge credit to
you. They couldn’t have been a more
caring or considerate whilst helping us
through a difficult time. They are true
diamonds.’
Ward C ‘The care for my mother has been
outstanding.’
Ward J ‘Nursing care fantastic.
Continuous empathy towards mum
and family.’
Ward D ‘It was confusing with the two
options. We were getting one off the
consultant and another off the ward
sister. (Consultant told us just to carry on
as normal till the worse happens). Sister
told us to be on constant bed watch.’
Ward K ‘We felt excellent care given
to mum and ourselves. Couldn’t have
expected anything better.’
Ward L ‘Wonderful support and care for
my father and my family.
Ward E ‘I found it (carers diary) very easy
to fill in.’
Ward F ‘There could be more information
available on what the next steps are
when there is a bereavement.’
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Annual Quality Account 2012-2013
This diary has been recommended by NHS Innovations to be considered for roll-out nationally.
The impact of treating patients with compassion has a direct link to what patients and
relatives/carers think about our organisation.
Carers diary
Since the research in 2010/11 our carers diary (now known as the ‘Family’s Voice’) was
provided to the family or carers of 350 hospital patients placed on the end of life care
pathway. The diary provided an opportunity for family/carers to score the quality of end of life
care in relation to a number of key quality domains, these being:
•pain;
•breathlessness;
•nausea (sickness);
•restlessness;
•staff care of the patient;
•staff care of the carers.
The comments made in these diaries provided staff with a vital opportunity to quickly
understand what they are doing well and how they might improve actual and perception of
care for each individual patient and their carers. Any score below 25 would indicate that the
relative/carer perceived that a suboptimal quality of symptom control or experience of care
was provided.
Use of the carers diary will enable the Trust to review scores and trends over time. It provides
an opportunity for staff to put things right and where appropriate for additional
support and training to be put in place to enable Trust staff to influence perception of care so
that we continuously meet patient and carer expectations.
In almost two years (21 months) we have received only one complaint about end of life care
from patients where the carer’s diary has been used.
Nutrition:
Rationale: good nutrition plays an important contribution to recovery from illness or injury.
Our stakeholders and our commissioners are joined by our staff in agreeing that nutrition
should be a priority for all patients. We have good standards of nutrition for adult inpatients
so we will focus on nutrition for children and in the outpatient setting.
Hospital Healthcare
Overview of how we
said we would do it
Overview of how we said
we would measure it
Overview of how we
said we would report it
• Introduce the
malnutrition
universal screening
tool (MUST) that
we use for adult
inpatients into the
outpatient setting.
• We will train staff to use
the MUST and STAMP
tools.
• Results of audits will be • Progress reported
reported to the IPNMB
to PS & QS.
every 6-months.
• Progress reported
• To the Nutrition
quarterly to
Advisory Group (NAG).
IPNMB.
✔
• Introduce the
screening tool for
the assessment
of malnutrition in
paediatrics (STAMP)
into in-patient
paediatric wards.
• We will collect baseline
audit by June 2012.
• Progress reported
to commissioners.
✔
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Annual Quality Account 2012-2013
• We will introduce the
tools into outpatient
and paediatric inpatient
areas.
• We will collect baseline
audit by June 2012.
How did we do?
✔
Nutrition
Following patient feedback the catering team has implemented further improvements
following the successful introduction of the ward hostess service throughout all wards in
our hospitals. Our hostesses have a specific aim of improving the patient enjoyment
of food. This ward hostess strategy continues to prove an extremely successful catalyst for
improvements in patient experience by ensuring patients always get their meal of choice,
well presented and hot. This initiative has also greatly assisted the reduction of food waste
averaging by 30% to enable re-investment in improved menu, modified consistency meals
and other important patient recommendations.
Menu choice is regularly reviewed and is now based on choices familiar with the age of
patients on elderly care wards and on children’s wards. Frequent snacks and finger foods are
available throughout the day for these patients.
For patients with dementia and disability we have introduced coloured, light-weight,
easy-to-handle utensils. Feedback from our patients demonstrates that they find it much
easier to use these. Picture cards with photographs, drawings and words enable the
cognitively impaired to understand and chose what they want.
We are also looking to purchase half litre water jugs which are easier to lift and use.
Catering assistant Sherry Smith.
Therapy assistant Chris Ferguson.
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Annual Quality Account 2012-2013
2B: Quality improvement priorities for 2013-14
Introduction to 2013-2014 Priorities
Key priorities for improvement for 2013-2014 have been agreed through consultation
with patients, staff, governors, local involvement networks, commissioners, health scrutiny
committees and other key stakeholders. We started the consultation period at the beginning
of September 2012, which allowed us to consult widely and provide stakeholders with a
significant opportunity to consider and suggest the priorities that they would like to see us
address. Feedback and third party declarations have been invited from formal stakeholders.
Full details of stakeholder feedback can be found in section 3C. Our governors continue to be
actively involved in assisting us in setting our priorities.
The Trust continues to develop quality improvement, capacity and capability to deliver our
priorities as demonstrated throughout this Quality Account.
We would like to thank all of those involved in setting priorities for 2013-14 which are linked
to patient safety, effectiveness of care and patient experience. We all agree that our priorities
for improvement should continue to reflect three key principles, namely:
Don’t
harm me
Treat me
right the
first time
Be nice
to me
Stakeholder priorities
The quality indicators that our external stakeholders said they would like to see included
were:
Patient Safety
Effectiveness of Care
Patient Experience
1. Dementia
1. Discharge Processes Information
1. End of Life Pathway & Family's
Voice (Carers Diary)
2. Safeguarding Adults
(Learning Disabilities)
2. Discharge Processes Medication
2. Is our care good (Patient
Experience Surveys)
3. Infection Control (C diff)
3. Discharge Processes
(Safe and Warm)
3. Friends and Family
recommendation
4. Nursing Dashboard
Rationale for the selection of priorities
All of the quality indicators selected by external stakeholders have been incorporated into the
quality priorities for 2012-2013 leading into 2013-2014, in addition nursing staff asked that
the newly introduced dashboard for nursing outcomes should be reported.
The tables over the following pages will describe each priority, the rationale for including
it along with a summary of how we aim to achieve the outcome, measure the impact and
reporting arrangements.
We have incorporated feedback from patients, staff and visitors through our consultation
on the Trust’s RESPECT strategy, and through feedback from our dignity day campaign in
February 2012.
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Annual Quality Account 2012-2013
The Chief Nursing Officer launched a consultation document in September 2012 to which
we again consulted widely and provided feedback for consideration into the final documents
focusing on the six Cs:
•Care
•Compassion
•Competence
•Communication
•Courage
•Commitment
We have aligned outcomes where possible to quality indicators requested by commissioners.
Patient Safety
Priority 1: Improving care for people with dementia
Rationale: There are currently 14,000 people with a diagnosis of dementia across County
Durham & Darlington and Tees. NHS Hartlepool/Stockton on Tees has the highest projected
increase of dementia across the North East by 2025. All stakeholders identified dementia as a
key priority.
Hospital Healthcare
How will we do it
How will we measure it
How will we report it
• We will use the Stirling
Environmental Tool to adapt and
audit the impact on our hospital
environment.
• The Stirling Environmental audit
assessment tool will be used to
monitor the difference pre and
post adaptation.
• Dementia Strategy Group
quarterly.
• We will ensure that all patients
over 65 receive an Abbreviated
Mental Test (AMT) and are,
where appropriate referred for
further assessment.
• The percentage of patients who
receive the AMT and, where
appropriate, further assessment
will be reported quarterly.
• Integrated Professional Nursing
and Midwifery Board (IPNMB)
and PS & QS Quarterly.
Patient Safety
Priority 2: Safeguarding Adults with Learning Disabilities (LD)
All hospital patients will have a named advocate and an individualised plan of care.
Rationale: The Winterbourne View Review* identified a number of actions that service
commissioners and providers could undertake to prevent the terrible outcome suffered by
people with LD at Winterbourne View.
The Trust and Commissioners believe that people with LD should not be in hospital unless
absolutely necessary. When it is necessary to admit patients with LD, they must have an
individualised plan of care and a named advocate.
Hospital Healthcare
How will we do it
How will we measure it
How will we report it
• All patients with LD will be
referred on admission to the LD
specialist nurse.
• Audits will be carried out and
results reported.
• Audit results and Action Plans to
be reported to IPNMB quarterly.
• The LD Specialist nurse will act
as the named advocate and will
ensure that an individualised
plan of care is in place and
reasonable adjustments
documented.
* The national response to The Winterbourne Review report can be accessed on
www.wp.dh.gov.uk/publications/files/2012/12/final-report.pdf
Annual Quality Account 2012-2013
31
Patient Safety
Priority 3: Infection Prevention and Control (IPC): Clostridium Difficile (C diff)
To continue to reduce the number of avoidable hospital acquired cases of clostridium difficile.
Rationale: C diff remains a burden across the community and hospitals in the Hartlepool
and Tees areas. The Trust breached its C diff target in 2012. Stakeholders and the Trust believe
that reducing C diff should remain a key priority for 2013-2014.
Hospital Healthcare
How will we do it
How will we measure it
How will we report it
• We will closely monitor testing
regimes, antibiotic management
and repeat cases and ensure we
understand and manage the root
cause wherever possible.
• We will monitor the number
of hospital and community
acquired cases.
• Public Board meetings.
• We will undertake a multidisciplinary Root Cause Analysis
(RCA) within 3 working days.
• Infection Control Committee
(ICC).
• We will define avoidable
and unavoidable for internal
monitoring.
• We will benchmark our progress
against previous months and
years.
• Council of Governor meetings
(CoG).
• Patient Safety and Quality
Standards Committee (PS & QS).
• To frontline staff through Chief
Executive brief.
• Nursing Dashboard.
• We will benchmark our position
against Trusts in the North East
in relation to number of cases
reported; number of samples
sent for testing and age profile
of patients.
Patient Safety
Priority 4: Dementia
All hospital patients will have a named advocate and an individualised plan of care.
Rationale: In 2012 the Trust signed up to the Right Care: Creating Dementia Friendly
Hospital. Along with key stakeholders, the Trust believes that patients with dementia receive
the right treatment in the right place.
Community Healthcare
How will we do it
How will we measure it
How will we report it
• Patients with dementia will
be appropriately assessed and
referred on to specialist services.
• We will audit the number of
patients over 75 admitted as an
emergency that are reported as
having a known diagnosis of
dementia, or have been asked
the (Prime Ministers) dementia
case finding question.
• To the IPNMB.
• A monthly audit of the percent
of patients who are screened,
assessed and referred for
specialist review.
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Annual Quality Account 2012-2013
• To the Board of Directors.
Effectiveness of Care
Priority 1: Discharge processes – Information/Communication
Rationale: Although quality of discharge information has improved considerably over the
years, this remains a priority with further improvements recommended by stakeholders.
Hospital & Community Healthcare
How will we do it
How will we measure it
How will we report it
• All patients discharged to a
nursing or care home requiring
district nurse review, will receive
a written summary of care
provided and of ongoing care
required.
• Audit a number of patients
discharged with a letter.
• To the IPNMB.
• A copy will be provided to the
home or district nurse.
Effectiveness of Care
Priority 2: Discharge processes – Medication
Rationale: The latest national patient experience survey identified that the percentage of
patients told about medication side-effects to watch out for at home had reduced by 5%.
Hospital & Community Healthcare
How will we do it
How will we measure it
How will we report it
• All patients will receive
information about medication
side-effects to watch out for at
home.
• Via national and local patient
surveys.
• Local audit reports twice yearly
to IPNMB and PS & QS.
• National audit report to PS & QS.
Effectiveness of Care
Priority 3: Discharge and transfer processes – Safe and warm
Rationale: Following receipt of a complaint in December 2012, the Trust has included Safe
and Warm discharge and transfer as an additional measure for 2013-2014.
Hospital & Community Healthcare
How will we do it
How will we measure it
How will we report it
• We will deliver a ‘Safe and
Warm’ campaign.
• Referrals to the ‘Stay Safe and
Warm Campaign Scheme' will be
monitored.
• Annual report to IPNMB from
Tees wide Vulnerable Adults
Patient Experience Group.
• We will review our protocols
for transferring and discharging
patients to ensure that blankets
are always provided and are
adequate to maintain warmth
throughout the patient journey.
• We will liaise with the ambulance
services and staff to ensure
patients are kept warm until they
arrive at their destination.
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Annual Quality Account 2012-2013
Effectiveness of Care
Priority 4: Nursing Dashboard
Rationale: The Nursing Dashboard will support close monitoring of nurse sensitive patient
outcomes on a day-to-day basis. It will support sharing of best practice and speedy review of
any potential areas of concern.
Hospital Healthcare
How will we do it
How will we measure it
How will we report it
• Training will be completed and
each department will evidence
that their results have been
disseminated and acted upon.
• SCMs will monitor ward areas to
ensure that data is up to date,
accurate and displayed in a
public area.
• Monthly dashboard analysis to
the Director of Nursing
• Ward matrons will present their
analysis on a public area of the
ward for patients and staff to
see. The results will be discussed
and minuted.
• Quarterly to Senior Matron and
General Manager meeting and
IPNMB
To note: For Community, there will be a Community Nursing Dashboard developed and
rolled out during 2013-2014. This is dependent on integrated IT systems being in place.
Patient Experience
Priority 1: End of Life Pathway and Family’s Voice
Rationale: The Trust has made excellent progress in rolling out use of the Family’s Voice.
Stakeholders and the Trust believe that this needs to remain a priority in 2013-2014 both in
hospital and in the community.
Hospital Healthcare
How will we do it
How will we measure it
How will we report it
• We will continue to embed use
of the Family’s Voice in hospital
and continue to roll its use out in
the community.
• We will evaluate feedback
in relation to pain, nausea,
breathlessness restlessness,
care for the patient and care for
the family.
• Quarterly to IPNMB
• Annually to PS & QS
Patient Experience
Priority 2: Is our care good?
Rationale: Trust and key stakeholders believe that it is important to ask this question through
internal and external reviews.
Hospital Healthcare
How will we do it
How will we measure it
How will we report it
• We will ask the question to every
patient interviewed in the Patient
Experience and Quality Standards
(PEQS) reviews.
• We will analyse feedback from
PEQS and patient experience/
national surveys.
• Six monthly reports to IPNMB
and to PS & QS.
• We will ask the question in all
Trust patient experience surveys.
• We will monitor patient feedback
from national surveys.
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Annual Quality Account 2012-2013
Patient Experience
Priority 3: Friends and Family recommendation.
Rationale: The Department of Health require Trusts to ask the Friends and Family
recommendation questions from April 2013. Stakeholders agree that this should be
implemented and reported in the 2013-2014 Quality Account and Report.
Hospital Healthcare
How will we do it
How will we measure it
How will we report it
• We will incorporate the Friends
and Family test wording into
PEQS and patient surveys.
• We will analyse feedback from
PEQS and patient surveys and
discharge questionnaires.
• Quarterly to IPNMB
and to PS & QS.
• We will ask patients to complete
a questionnaire on discharge
from hospital.
Part 2C: Statements of Assurance from the Board
Review of Services
During 2012-2013 North Tees and Hartlepool NHS Foundation Trust provided and/or
subcontracted 64 NHS services. The majority of our services were provided on a direct basis,
with a small number under sub-contracting or joint arrangements with others.
We have reviewed all of the data available to us on the quality of care in all of these NHS
services. The income generated by the NHS services reviewed in 2012-2013 represents 100%
of the total income generated from the provision of NHS services by the Trust for 2012-2013.
The data reviewed aims to cover the three dimensions of quality: patient safety; clinical
effectiveness, and patient experience. In a number of areas there has been no benchmark
data available. Where benchmark data has been available, it has been included.
Participation in clinical audits
All NHS Trusts are audited on the standards of care that they deliver and our Trust participates
in all mandatory national audits and national confidential enquiries.
The CQC quality risk profile rated the Trust as green in relation to assessing and monitoring
the quality of service provision throughout 2012-2013. The CQC quality risk profile is
included under the Care Quality Commission section of this report.
The Healthcare Quality Improvement Partnership (HQIP) provides a comprehensive list of
national audits which collected audit data during 2012-2013 and this can be found on the
following link:
www.hqip.org.uk/national-clinical-audits-for-inclusion-in-quality-accounts/#QA
During 2012-2013, 37 national clinical audits and five national confidential enquiries covered
the NHS services that we provide. During that period we participated in all 37 national clinical
audits and five national confidential enquiries.
This represents 100% of all mandatory national clinical audits and 100% of all mandatory
national confidential enquiries. We did not participate in all non-mandatory audits as we
have a small audit team.
The national clinical audits and national confidential enquiries that we were eligible to
participate in during 2012-2013 are listed below. This list also identifies those national clinical
audits and national confidential enquiries that the Trust participated in during this period.
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Annual Quality Account 2012-2013
The national clinical audits and national confidential enquires that the Trust participated in,
and for which data collection was completed during 2012-2013, are listed below alongside
the number of cases submitted to each audit or enquiry as a percentage of the number of
registered cases required by the terms of that audit or enquiry.
Audit title
Participation
M = Mandatory
N = Non-Mandatory
% cases submitted
Adult community acquired pneumonia
(British Thoracic Society)
Yes (N)
Data collection ongoing
Adult critical care
(Case Mix Programme – ICNARC CMP)
Yes (N)
Data collection ongoing
Emergency Laparotomy
(Royal College of Anaesthetists)
Yes (M)
Audit to commence in 2013
Emergency use of oxygen (British Thoracic Society)
Yes (N)
100%
National Joint Registry (NJR)
Yes (M)
Data collection ongoing
Non-invasive ventilation – adults
(British Thoracic Society)
Yes (N)
100%
National Confidential Enquiry Patient Outcome
and Death (NCEPOD)
Yes (M)
Data collection ongoing
Renal colic (College of Emergency Medicine)
Yes (N)
100%
Severe trauma (Trauma Audit & Research Network)
Yes (N)
Data collection ongoing
National Comparative Audit of Blood Transfusion
- programme contains the following audits, which
were previously listed separately in Quality Account:
a) O negative blood use (2010/11)
b) Medical use of blood (2011/12)
c) Bedside transfusion (2011/12)
d) Platelet use (2010/11)
Yes (N)
100%
Potential donor audit (NHS Blood & Transplant)
Yes (N)
Data collection ongoing
Bowel cancer (NBOCAP)
Yes (M)
100%
Lung cancer (NLCA)
Yes (M)
100%
Oesophago-gastric cancer (NAOGC)
Yes (M)
100%
Acute coronary syndrome or Acute myocardial
infarction (MINAP)
Yes (M)
Data collection ongoing
Heart failure (HF)
Yes (M)
Data collection ongoing
National Cardiac Arrest Audit (NCAA)
Yes (N)
Data collection ongoing
Adult asthma(British Thoracic Society)
Yes (N)
100%
Asthma Deaths (NRAD)
Yes (M)
100%
Bronchiectasis
(British Thoracic Society)
Yes (N)
100%
COPD (Royal College of Physicians) Please note:
this is NOT the COPD audit run by the British
Thoracic Society)
(M)
Audit to commence 2013
Diabetes (Adult) ND(A), includes National Diabetes
Inpatient Audit (NADIA)
Yes (M)
100%
Diabetes (Paediatric) (NPDA)
Yes (M)
100%
Inflammatory bowel disease (IBD) Includes:
Paediatric Inflammatory Bowel Disease Services
(previously listed separately on 2010/11 quality
accounts list)
Yes (M)
Data collection ongoing
Pain database
Yes (M)
100%
Fractured neck of femur
(College of Emergency Medicine)
Yes (N)
100%
Hip fracture database (NHFD)
Yes (M)
Data collection ongoing
National dementia audit (NAD)
Yes (M)
100%
Parkinson's disease (National Parkinson's Audit)
Yes (N)
100%
Sentinel Stroke National Audit Programme (SSNAP)
- programme combines the following audits, which
were previously listed separately in Quality Account:
a) Sentinel stroke audit (2010/11, 2012/13)
b) Stroke improvement national audit project
(2011/12, 2012/13)
Yes (M)
Data collection ongoing
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Annual Quality Account 2012-2013
Audit title
Participation
M = Mandatory
N = Non-Mandatory
% cases submitted
Elective surgery (National PROMs Programme)
Yes (N)
80.3% (based on return rate of
patient questionnaires)
Child Health (CHR-UK)
Yes (M)
100%
Epilepsy 12 audit (Childhood Epilepsy)
Yes (M)
100%
Maternal infant and perinatal (MBRRACE-UK)
Yes (M)
100%
Neonatal intensive and special care (NNAP)
Yes (M)
100%
Paediatric asthma (British Thoracic Society)
Yes (N)
100%
Paediatric fever (College of Emergency Medicine)
Yes (N)
100%
Paediatric intensive care (PICANet)
Yes (M)
100%
Paediatric pneumonia (British Thoracic Society)
Yes (N)
Data collection ongoing
Consultant sign-off
(College of Emergency Medicine)
Yes (N)
100%
The Trust participated in all five national confidential enquiries (100%) that it was eligible to
participate in, namely:
National Confidential Enquiries (NCEPOD)
NCEPOD Cardiac Arrest Procedures (Time to Intervene?)
NCEPOD Bariatric Surgery Study (Too Lean a Service?)
NCEPOD Alcohol Related Liver Disease Study (data collection ongoing)
NCEPOD Subarachnoid Haemorrhage Study (data collection ongoing)
NCEPOD Tracheostomy Care Study (study just commenced)
Confidential Maternal and Child Health Enquiries (CMACE)
The Trust provides information to these national enquiries for all maternal, perinatal (the
period shortly before and after birth) and child deaths through the Regional Maternity Survey
Office (RMSO) and the North East Public Health Observatory (NEPHO). Participation in this
audit provides useful benchmarking data across the North East.
MBRRACE-UK has been appointed by the Healthcare Quality Improvement Partnership
(HQIP) to continue the national programme of work investigating maternal deaths, stillbirths
and infant deaths, including the Confidential Enquiry into Maternal Deaths. The aims of
MBRRACE-UK are to provide robust information to support the delivery of safe, equitable,
high quality, patient-centered maternal, newborn and infant health services. Nationally there
are future plans to include a new programme of audit for maternal deaths, late fetal losses,
still births and infant deaths. The Trust intends to participate.
The maternity, neonatal and paediatric teams will continue to provide information relating
to all child deaths from birth to 18 years of age to the RMSO office and the Child Death
Overview Panels that review all child deaths on behalf of the Local Safeguarding Children’s
Boards. This allows for a multidisciplinary review of data and analysis for any trends and
shared learning relating to these deaths.
The Trust also provides details to the North East Public Health Observatory (NEPHO) to help
collate data including diagnosis and incidences of congenital abnormalities; management
and outcome data from multiple pregnancies; and diabetes in pregnancy. This data is
analysed regionally and included in national analysis.
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Annual Quality Account 2012-2013
Commendations on our participation and performance
In the latest National Cancer Patient Experience Survey (received 2012), the Trust was rated
in the top 20% nationally for over 60% of all responses, with the Trust achieving the highest
responses in the country for two questions:
•Patients being told to bring a friend when they were first told they had cancer
•Providing GPs with enough information about diagnosis and treatment.
The Trust was invited to present its work on (NICE50 guideline; reducing deterioration) at the
national NICE conference in 2012.
National Clinical Audits
The Department of Health holds a comprehensive list of National Audits which can be found at:
www.dh.gov.uk/health/tag/quality-accounts/
The reports of 13 national clinical audits were reviewed by the Trust in 2012-2013 resulting in
the following actions to improve the quality of healthcare provided:
Audit title
Actions taken
National Care of the Dying Audit
Introduction of the Family’s Voice to complement the Liverpool End of
Life Care Pathway.
National Decreased Consciousness
Audit (Paediatrics)
Local audit between the Paediatric and Accident and Emergency (A&E)
departments.
UK Inflammatory Bowel Disease Audit
Named pharmacist identified.
National Inpatient Survey 2011
Reintroduction of red trays in selected wards to alert staff to the patient
who may need assistance at meal times.
We have introduced a Nurse for the Older Person and Dementia Nurse
Specialists to assist.
We use Intentional Rounding and PEQS reviews to monitor patient
experience.
National Outpatient Survey 2011
Detailed patient survey looking at issues such as communication,
information provided and privacy and dignity.
Specialty specific Customer Care Charters highlight the importance of
effective communication, appropriate behaviour and standards of good
practice.
National Parkinson’s Disease Audit
2011
Communication processes that involve Driver and Vehicle Licensing
Agency (DVLA) have been enhanced.
NCEPOD report, Time to intervene?
A six-monthly audit to monitor quality of medical assessment on
admission has been developed.
National Epilepsy 12 audit
Improvements to documented classification of seizure agreed with
visiting neurologists.
College of Emergency Medicine
National Audit: Consultant sign-off
Emergency Department Information System (EDIS) is being adapted to
enable an electronic consultant signoff field.
College of Emergency Medicine
National Audit: Pain Management in
Children
Audit in A&E department to monitor pain management following initial
assessment.
College of Emergency Medicine
National Audit: Severe Sepsis and
Septic Shock
Local audits developed to monitor documentation of oxygen therapy and
urine output.
National Cancer Patient Experience
Survey 2011
Task and Finish Group established to improve patient understanding of
resources available from local authorities.
Information about free prescriptions being provided by Clinical Nurse
Specialists.
BTS Emergency Oxygen Audit
38
Annual Quality Account 2012-2013
Prescription sheet revised in line with best practice. Further audits.
Local Clinical Audits
The reports of 42 local clinical audits were reviewed by the Trust in 2012-2013 and the Trust
intends to or has commenced the following actions to improve the quality of healthcare
provided as follows:
Local audit title
Actions taken/in progress
Fluid Balance Management in Theatres
Bespoke staff training.
A Standard Operating Procedure (SOP) and audit tool has been
developed to monitor compliance.
Assessment of Safe Prescribing
Safe prescribing training tests developed as part of junior doctor
induction
Hypertension Audit
Assessment and management of hypertension risk in pregnancy.
Audit plan agreed.
Evaluation of Acute Knee Soft Tissue
Injury Clinic Pathway
Referral criteria updated. To be audited in 2013
Prescription and Treatment for Postoperative Nausea and Vomiting (PONV)
Regular prescription of anti-emetics by anaesthetists to be audited
in 2013.
Stroke Management in the Emergency
Department
The ROSIER stroke assessment tool will be used regularly to enable
improved stroke diagnosis.
In-Patient Medical Management of
Anorexia
Development of enhanced guidelines and training for staff.
The Trust continues to perform well in audit activity and positive points to note include:
Local audit title
Good practice
Neutropenic Sepsis Audit
An education programme and posters have been introduced to
increase Neutropenic Sepsis awareness.
Cardiac Rehabilitation – Clinical
Outcomes in the Community
Patients have given very positive feedback. Average weight, BMI and
alcohol intake have reduced.
Diabetes Inpatient Foot
Assessment Audit
A proforma for foot assessment has been developed and implemented.
This ensures that foot assessment is undertaken at the time of
admission by the admitting doctor and that there is continuing patient
assessment by nursing staff.
Vascular Disease
Antiplatelet agents are in line with best practice for both Transient
Ischaemic Attack (TIA) and Stroke.
MUST Nutritional Assessment Tool
Bi annual audits undertaken in 2012 to continue in 2013
Thromboprophylaxis Following Normal
Vaginal Delivery
There is near 100% compliance with guidance.
Anaesthetic Techniques for Caesarean
Section
We achieve high level compliance with Royal College Guidance
The Diagnosis & Management of
Epididymo-Orchitis
New local guidelines have being developed for diagnosis
World Health Organisation (WHO)
Alcohol Audit
Good compliance with the guidance – patients are being correctly
referred to an Alcohol Specialist Nurse and are appropriately assessed
and supported.
All national audit reports are considered by the Audit and Clinical Effectiveness (ACE)
Committee which reports to the Patient Safety and Quality Standards (PS & QS) committee,
PS & QS reports directly to the Board of Directors. The ACE committee is chaired by an
Associate Medical Director and includes patient representatives.
The Department of Health’s National Cancer Patient Experience Survey 2011 identified that
improvements have been made in relation to patient experience across a number of areas
measured, with 62% (up from 59% in 2010) of all results being in the top 20% nationally.
The full report can be found at:
www.quality-health.co.uk/images/stories/pdfs/2012CancerReports/2011-12cancerpatientexpe
riencesurveynationalreport.pdf
39
Annual Quality Account 2012-2013
Participation in Research
The Research and Development (R&D) Department continues to embed research into the
culture of the Trust through:
•More patients being recruited into National Institute for Health Research (NIHR) portfolio
studies;
•More staff benefiting from the R&D Incentive Funding of higher research degrees and
qualifications;
•Increased numbers of staff trained in Good Clinical Practice (GCP);
•Involvement of new clinical specialisms in research activity.
We remain committed to actively encouraging participation into NIHR portfolio research
studies as part of our membership agreement with County Durham & Tees Valley
Comprehensive Local Research Network (CDTV CLRN). We have 151 active studies registered
with the department, 116 of these (77%) are NIHR portfolio studies.
The total number of patients receiving NHS services provided or subcontracted by the Trust in
2012-2013, who were recruited during that period to participate in research, approved by a
research ethics committee, was 1,663.
The table below shows the year on year increases seen in this Trust for portfolio study
recruitment (figures correct as at 08/04/2013).
Figure 1. NIHR Portfolio recruitment
NIHR portfolio Study recruitment
2,000
1,800
1,663
1,600
1,400
1,200
1,147
1,000
800
600
400
200
412
455
2009/10
2010/11
159
0
2008/09
2011/12
2012/13
Other achievements to date are summarised below:
•In the Guardian Research League tables 2011/12 our Trust ranked 143rd best nationally
in the 'All Trusts' category (397th the previous year). In the 'Acute Trusts - medium sized'
category we ranked 16th best in the country 2011/12. Data for 2012/13 was not available
at the time of going to print;
•The Trust R&D Incentive fund has funded £49,564 of training, research support and course
fees within the Trust over the last year. Through the R&D Incentive Fund, we were able to
deliver 3 training sessions in Good Clinical Practice for Research (GCP) since the last annual
report. In total, 71 members of staff attended GCP training in March and November
2012 and March 2013. 155 members of staff are currently trained in GCP. The course is
intended as a refresher every two years for staff who already hold a GCP certificate and an
introductory course for those new to research;
40
Annual Quality Account 2012-2013
Clinical respiratory research nurse June Battram and specialist respiratory nurse Karen Galloway.
There are 56 members of staff acting as Principal Investigator/Local Collaborators in research
within the Trust, some of whom are contributing to 10 studies;
•The CLRN funds 17 research nurses within the Trust. These nurses are working a range
of whole time equivalents from a few hours a week to full time on research studies. Our
bi-monthly research nurses working group continues to be well attended and provides
professional support and mentorship;
•The 2012 R&D conference was once again a great success with notable interest in the
keynote lecture from Professor Alastair Burt. Overall of the 88 people who attended, 98%
rated it as either excellent (50%) or good (48%) in terms of overall opinion of the day;
•Participation in commercially sponsored portfolio research is an NIHR priority. We have eight
commercially sponsored studies active within the Trust with plans for more in 2013. We
plan to use the revenue created through overhead fees in these studies to create additional
self-funded research posts within the relevant directorates;
•The R&D seminar series was held in September 2012 and was attended by 42 members
of staff. Evaluation feedback received indicated 94% felt it was relevant to their role, for
97% the seminars met their expectations, 100% found it beneficial, and 97% were likely to
recommend it in future, whilst 100% would be likely to attend in the future;
•Our staff have presented their research at nine national conferences, eight international
conferences and 28 papers have been published in peer reviewed journals;
•We have continued to streamline our research governance processes and consistently
perform well within the NIHR performance metrics of providing R&D approval for portfolio
studies approved within the NIHR Co-ordinated System for gaining NHS Permissions (CSP)
within 30 days (median for our Trust nine days);
41
Annual Quality Account 2012-2013
Commissioning for quality and innovation (CQUIN)
A proportion of North Tees and Hartlepool NHS Foundation Trusts income in 2012-13
was conditional upon achieving quality improvement and innovation goals with any person
or body they entered into a contract, agreement or arrangement with for the provision of
relevant health services, through the Commissioning for Quality and Innovation payment
framework.
The total income received through achievement of CQUIN goals in 2012-2013 is
£4,279,015.45* which includes £3,678,332.75* for acute and £600,682.71* for
community services.
Further details of the agreed goals for 2012/13 for the following 12 month period are
available online at:
www.monitor-nhsft.gov.uk/sites/all/modules/fckeditor/plugins/ktbrowser/_openTKFile.
php?id=3275
To note: 2012-2013 Quarter 4 data not validated at time of print.
The total income received through achievement of CQUIN goals in 2011-2012 was
£3,168,181 which included £2,793,077 for acute and £375,104 for community services.
Care Quality Commission (CQC)
Like all NHS Trusts, North Tees and Hartlepool NHS Foundation Trust is required to register
with the Care Quality Commission and its current registration status is registered without
conditions for all services provided.
Results of unannounced CQC inspections
During February 2013 the Trust received an unannounced back-to-back visit covering both
hospital sites. The following outcomes were reviewed at each site:
North Tees
Outcome
Regulation
4
9
Description
Care and welfare of people who use services
10
15
Safety and suitability of premises
13
22
Staffing
17
19
Complaints
Hartlepool
Outcome
Regulation
1
17
Description
Respecting and involving people who use services
4
9
Care and welfare of people who use services
12
21
Requirements relating to workers
17
19
Complaints
A written report has now been received from CQC assessors and it gave no recommendations
and very positive feedback to Trust personnel. The final report will be available from the Trust
and on the CQC website.
The Trust has undertaken provider compliance assessments against these standards and
introduced a shared repository for the collection of supporting evidence.
42
Annual Quality Account 2012-2013
This allows all Trust staff to access the data to facilitate understanding of the requirements
within the remit of their particular role or profession. It also enables the CQC to assess the
Trust's evidence of compliance more easily.
Confirmation of no enforcement action
We are happy to confirm that the Care Quality Commission (CQC) has not taken enforcement
action against the Trust during 2012/13.
Participation in CQC reviews
At the time of writing the Trust has not participated in any special review or investigation by
the CQC during the reported period.
The Trust has received a letter from the CQC in November 2012 regarding the number of hip
revision surgery undertaken.
The Trust was able to respond, as its surgeons were responsible for finding problems regarding
Metal on Metal hip surgery. Trust surgeons alerted the Medicines and Healthcare Authority
(MHRA) who subsequently issued a national alert. The Trust was the first in the country to
implement a recall programme and offer revision surgery for this group of patients.
Trust CQC Quality Risk Profile
The CQC provides a Quality Risk Profile (QRP) for all NHS Trusts. The QRPs are updated on
a regular basis and take into consideration all information, internal and external, which is
collected by them from up to 50 different sources in relation to every Trust. They are used to
help monitor compliance against the CQC Essential Standards of Quality and Safety. More
information on the essential standards and other CQC assessments can be found on the
following link: www.cqc.org.uk.
The Trust QRP ratings are shown on the following tables and these demonstrate that the Trust
is sustaining very good performing across all essential standards.
There are eight ratings that can be assigned to Trusts. The highest possible [best] rating is
low green and the lowest [worst] possible rating is high red. An additional two criterion for
no data or insufficient data are also used (see CQC diagram overleaf).
Birthing centre staff at the University Hospital of Hartlepool.
43
Annual Quality Account 2012-2013
Outcome Descriptions
1. Respecting and involving people who use services
2. Consent to care and treatment
4. Care and welfare of people who use services
5. Meeting nutritional needs
6. Cooperating with other providers
7. Safeguarding people who use services from abuse
8. Cleanliness and infection control
9. Management of medicines
10. Safety and suitability of premises
11. Safety, availability and suitability of equipment
12. Requirements relating to workers
13. Staffing
14. Supporting staff
16. Assessing and monitoring the quality of service provision
17. Complaints
18. Records
Risk Estimates Over Time
Period
Outcome 1
Outcome 2
Outcome 4
Outcome 5
Outcome 6
Outcome 7
Outcome 8
Outcome 9
Mar-12
Low Green
High Green
Low Green
Low Yellow
Low Green
High Green
High Green
High Green
May-12 Low Green
Low Green
Low Green
Low Yellow
High Green
Low Green
High Green
Low Green
Jun-12
Low Green
Low Green
Low Green
Low Yellow
Low Yellow
Low Green
Low Green
Low Green
Jul-12
Low Green
Low Green
Low Green
Low Green
Low Yellow
Low Green
Low Green
Low Green
Sep-12
Low Green
Low Green
High Green
High Green
High Green
Low Green
High Green
Low Green
Oct-12
Low Green
Low Green
High Green
High Green
High Green
Low Green
Low Green
Low Green
Nov-12
Low Green
Low Green
High Green
High Green
Low Green
Low Green
High Green
Low Green
Jan-13
Low Green
Low Green
Low Yellow
High Green
High Green
High Green
High Green
Low Green
Feb-13
Low Green
Low Green
Low Yellow
High Green
Low Green
High Green
High Green
Low Green
Mar-13
Low Green
Low Green
Low Yellow
High Green
Low Green
High Green
Low Yellow
Low Green
Period
Outcome 10 Outcome 11 Outcome 12 Outcome 13 Outcome 14 Outcome 16 Outcome 17 Outcome 21
Mar-12
Low Yellow
Low Yellow
Low Green
Low Green
Low Green
Low Green
Low Green
Low Green
May-12 High Green
Low Yellow
Low Green
High Green
Low Green
Low Green
Low Green
Low Green
Jun-12
High Green
Low Yellow
Low Green
High Green
Low Green
Low Green
Low Green
Low Green
Jul-12
Low Green
High Green
Low Green
Low Green
Low Green
Low Green
Low Green
Low Green
Sep-12
Low Green
High Green
Low Green
Low Green
Low Green
Low Green
High Green
Low Green
Oct-12
Low Green
High Green
Low Green
Low Green
Low Green
Low Green
Low Green
Low Green
Nov-12
Low Green
High Green
Low Green
Low Green
Low Green
Low Green
Low Green
Low Green
Jan-13
Low Green
High Green
Low Green
Low Green
Low Green
Low Green
Low Green
Low Green
Feb-13
Low Green
Low Yellow
Low Green
Low Green
Low Green
Low Green
Low Green
Low Green
Mar-13
Low Green
Low Yellow
Low Yellow
High Green
Low Green
Low Green
Low Green
Low Green
44
Annual Quality Account 2012-2013
CQC National Accident and Emergency Survey results 2012
In 2012, the CQC ran a national accident and emergency survey. Thirty-seven questions were
asked with the Trust scoring better than other Trusts nationally in 8% of questions. 92% of
the questions asked scored about the same as other Trusts, with no questions scoring worse. The Trust scored better nationally for three questions, these being;
1. Were you given enough privacy when being examined or treated?
2. Before you left the A&E Department, did you get the results of your tests?
3. While in the A&E Department, did you ever see any posters or leaflets explaining how to
complain about the care you received?
The following table shows how the Trust performs in relation to the other Trusts nationally in
relation to scores for each section of the national accident and emergency survey.
Section heading
Score out of 10
for your Trust
How this score compares
with other Trusts
Travelling by ambulance (answered by those who travelled
by ambulance only)
9.40
Same
Reception and waiting
6.20
Same
Doctors and nurses
8.40
Same
Care and treatment
8.40
Same
Tests
8.70
Same
Hospital environment and facilities
8.20
Same
Leaving the A&E department (answered only by those who
were not admitted to hospital or a nursing home)
6.60
Same
Overall views on experience
7.40
Better
Quality of Data
Good quality information underpins the effective delivery of patient care and helps staff to
understand what they do well and where they might improve.
The Board of Directors attend regular development sessions and seminars to ensure that every
member of the Board is equipped to interpret data, challenge and oversee improvements
where necessary. They consider data provided with other intelligence including listening
to what patients are saying. Our executive and non-executive directors can often be seen
in clinical areas talking to patients and staff to ensure a fully informed and well rounded
approach to decision making.
The members of the Council of Governors are encouraged to test the data reports they
receive through participation in PEQS reviews. This enables governors to speak directly
to patients and staff and provides assurance that standards are aligned with information
reported.
The Trust Board and Council of Governors are presented with a data quality dashboard
comparing the benchmark position against other Trusts within the Strategic Health
Authority (SHA).
Non-executive Directors meet with the Director of Nursing and Clinical Governance
personnel on a regular basis to review incident related performance data.
They also undertake a quarterly review of complaints related data. This includes
monitoring all complaints reported in the previous quarter. A sample is selected for
further scrutiny. This provides independent assurance that complaints are dealt with
appropriately, in a timely fashion and that lessons are learned and actions taken when we
get things wrong.
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Annual Quality Account 2012-2013
Training staff in critical appraisal is a vital part of ensuring that evidence is considered
in an objective and balanced way. We develop clinical staff so that they have the skills and
knowledge to use evidence in a way that supports them to make the best clinical decisions.
The Deputy Clinical Effectiveness Manager has been training staff in critical appraisal for
over ten years. His courses have been recognised and adopted by the British Medical
Association (BMA) and the Department of Health (DH). They are now used in the UK,
Europe and the United States of America. He remains the highest ranked trainer
authorised by the BMA.
Additional assurance in relation to data quality is provided independently by Audit North.
This provides rigorous and objective testing of data collection and reporting standards.
Results of these independent audits are reported to the audit committee and provide the
Trust with independent appraisal of clinical, financial and business governance
standards. This process of internal audit enables the Trust to test quality assumptions and
pursue its philosophy of continual improvement. In order to test and improve quality of
data the Trust will continue to commission independent audits of its key business.
Smarter Board Reporting Tools
The Trust has employed a dedicated Quality Analyst to ensure data quality and to produce
clear, concise and accurate reports.
The Quality Analyst works and interacts with staff at all levels in the Trust, from ward to
board, including community services.
During 2012 additional data quality tools and dashboards have been developed by the
Quality Analyst to aid the Trust Board reporting system.
These analysis tools and dashboards offer a real-time view of the current status of each ward
in relation to falls, pressure ulcers, formal complaints, infections and compliments/complaints.
The Infection Database and Analysis tool offers a real time analysis of infection data relating
to C diff cases. These systems and reports ensure executive and non-executive directors are
empowered to challenge, scrutinise and derive appropriate levels of assurance.
The data quality tools and Dashboards created during 2012/2013 include:
•Nurses Dashboard
•Community Dashboard
•IPC Dashboard
•PEQS Database
•Clostridium Difficile Database
The tools that have been developed ensure that there are no duplications within the data,
the data is valid and that there is tangible analysis undertaken automatically, producing clear,
concise and accurate reports tailored to the target audience.
Actions to improve data quality going forward.
The Trust will be taking the following actions to further improve data quality:
•Audits on the data capture within the notes compared to data captured on PAS are carried
out for both inpatients and outpatients;
•The information team is expanding to provide the same data quality for SystmOne
(community IT system) as it currently provides for PAS;
•Increase the number of auditors within clinical coding;
46
•Harness full value from new dashboards during 2013.
Annual Quality Account 2012-2013
PAS Upgrade
The PAS upgrade was a pre-requisite for the upgrade of existing products - the postcoder
functionality (QAS) and the clinical coding module (Medicode). Both suppliers upgraded their
solutions to change the way the functionality was provided. In order to maintain both these
modules for the users, PAS was upgraded to the latest version.
Medicode now provides the coders with more functionality including the ability to record the
source for the codes e.g. case notes, discharge summaries.
NHS number and general medical practice validity
The Trust submitted records during 2012-13 to the national Secondary User Service (SUS) for
inclusion in the national Hospital Episodes Statistics (HES) for inclusion in the latest published
data. The percentage of records in the published data is shown in the following table:
Which included the patient’s valid NHS
number was:
%
Which included the patient’s valid
general medical practice code was:
%
Percentage for admitted patient care
99.40
Percentage for admitted patient care
100
Percentage for outpatient care
99.90
Percentage for outpatient care
100
Percentage for accident and emergency care
99.20
Percentage for accident and emergency care
100
*Data period April 12 – February 13
Information governance (IG)
Information governance means keeping information safe. This relies on good systems,
processes and monitoring. Every year we audit the quality of specific aspects of information
governance through the national information governance toolkit report. In 2012-2013 we
had to ensure that 95% of all of our staff had received information governance training. This
target was challenging, however we have continued to make significant progress with a total
of at least 96% of all staff trained during the year for the third year running.
The Trust Information Governance Assessment Report score overall for 2012-2013 was 81%
and this has been graded as GREEN. A green rating is achieved where Trusts achieve level 2
or above on all requirements (see following table).
We continue to provide assurance to the Trust Board that we are constantly assessing and
improving our systems and processes to ensure that information is safe.
Annual ratings of green (pass) or red (fail) are assigned to Trusts each year. The following
table shows progress with ratings when compared to the previous year.
Requirement
Information Governance Management
Corporate Information Assurance
Confidentiality and Data Protection Assurance
Clinical Information Assurance
Secondary Use Assurance
Information Security Assurance
2011-2012 rating
2012-2013 rating
Green
Green
93%
93%
Green
Green
66%
66%
Green
Green
83%
79%
Green
Green
73%
93%
Green
Green
83%
83%
Red
Green
75%
75%
The IG toolkit is available on connecting for health website.
www.igt.connectingforhealth.nhs.uk
47
Annual Quality Account 2012-2013
We receive a number of Freedom of Information (FOI) requests every year. In order to be
transparent about information we have been asked to provide, we have developed a virtual
reading room on our internet site. Since 1 January 2012, we have been posting responses to
Freedom of Information requests on the site and these can be viewed by the public on:
www.nth.nhs.uk/foirr
Clinical coding
Clinical coding translates medical terms written by clinicians about patient diagnosis and
treatment into codes that are recognised nationally.
The Trust was subject to the Payment by Results clinical coding audit during the reporting
period by the Audit Commission and the error rates reported in the latest published audit for
that period for diagnosis and treatment coding (clinical coding) were:
•Primary diagnoses correct
91.10%
•Secondary diagnoses correct
92.20%
•Primary procedures correct
84.20%
•Secondary procedures correct
84.60%
The services reviewed within the sample were 135 finished consultant episodes (FCEs) in
general medicine. The primary procedure has only 19 procedure codes to be audited and
three were found to have errors. To meet the 90% target there could have been only one
error. The results should not be extrapolated further than the actual sample audited.
The errors include both coder and documentation errors of which the coding errors will be
fed back to the coders as a group and individually. The documentation errors will be taken to
directorate meetings.
Depth of coding and key metrics is monitored by the Trust in conjunction with mortality
data. Monthly coding audits are undertaken to provide assurance that coding reflects clinical
management.
Our coders organise their work so that they are closer to the clinical teams. This results in
sustained improvements to clinical documentation. This supports accurate clinical coding
and a reduction in the number of Healthcare Resource Group changes made. This is the
methodology which establishes how much we should get paid for the care we deliver. We
will continue to work hard to improve quality of information because it will ensure that NHS
resources are spent effectively.
North Tees and Hartlepool Foundation Trust will be taking the following actions to
improve data quality. Specific issues highlighted within the audit have been fedback to
individual coders and appropriate training planned where required.
Coders currently code from discharge summaries within medicine which does not give them
a full detail therefore, in approximately 10 weeks time, coders will share access to paper light
records and scanned notes. A lead quality coder will be employed to provide assurance of
data quality in 2013-2014.
48
Annual Quality Account 2012-2013
Part 3: Review of Quality Performance
Part 3 of this Quality Account provides an opportunity for the Trust to report on progress
against additional quality indicators which are not included in part 2 ‘performance against
quality improvements priorities’.
Where possible we have provided additional sources of external data in section 3A to provide
members of the public with as much useful information as possible.
Part 3A of this report will describe Trust performance against local quality indicators.
Part 3B will describe Trust performance against national priorities from the Department of
Health Operating Framework, Appendix B of the Compliance Framework.
Part 3C contains the additional Department of Health Core Indicator Set, which includes
9 indicators. The data containted within this section comes from the NHS Information
Centre indicator portal (NHS IC).
Part 3A: Trust performance against additional
Quality Performance Indicators
In addition to the three local priorities outlined in part 2, the indicators below further
demonstrate that the quality of the services provided by the Trust over 2012-2013 has been
positive overall.
In keeping with the format of the Quality Account, additional indicators will be presented
under the headings of patient safety, effectiveness of care and patient experience.
Indicators chosen reflect indicators that have been or remain of interest to key stakeholders as
identified through consultation, discussion or enquiries.
The indicators that will be reported in this section include:
Patient safety
Effectiveness of care
Patient Experience
• MRSA bacteraemia.
• Pulmonary embolism (PE) or deep vein
thrombosis (DVT).
• You're welcome.
• SHMI.
• Medication Errors.
• Post-op Haemorrhage or Haematoma.
• Learning disabilities
(LD).
• Safety Thermometer.
• NEQOS effectiveness indicators.
• Pressure Ulcers.
• Safeguarding (adults and children).
• IPNMB.
• Complaints and
compliments.
• Sensory loss.
• PROMS.
The Quality Account this year reports on the indicators above, the only change from last
year's Quality Account is that we have not included delivering same sex accommodation.
The reason being is that the Trrust has had no breaches and continues to deliver the highest
standards of privacy and dignity for its patients.
The reason that these indicators are being reported is because the Trust and/or stakeholders
believe that these indicators should remain a focus for improvement for the coming year.
Further rationale is provided in relation to the individual outcomes of these indicators and are
shared on the following pages.
The Trust therefore felt that this indicator will only need to be reported on if this changes in
the future.
The remaining 2011-2012 Quality Account indicators remain in this section with additional
indicators being added.
Annual Quality Account 2012-2013
49
Patient Safety
1. Methicillin-Resistant Staphylococcus Aureus (MRSA) bacteraemia
The importance of personal hygiene is fully understood by all staff and is visible through the
bare below the elbow policy and the presence of alcohol gel dispensers and hand-washing
facilities. Further improvements to our environment and practices are constantly being
implemented and evaluated.
Many patients carry MRSA on their skin, this is called colonisation. It is important that we
screen patients when they come in to hospital so that we know if they are carrying MRSA.
Screening involves a simple skin swab. If positive, we can provide special skin wash that helps
to get rid of MRSA.
Our rate of screening for MRSA is very high and we believe that this has helped us to achieve
the results reported during the course of the last two years.
Screening patients on admission showed that around 200 patients every month bring MRSA
into hospital on their skin. This carriage will not harm them unless they become very poorly.
How did we do?
In 2012-2013, our organisation performed well against regional and national standards in
relation to almost all aspects of infection prevention and control and this reflects the hard
work of all staff, both clinical and non-clinical, in ensuring that high standards are maintained
all of the time. We reported two hospital MRSA bacteraemia during 2012-2013, having had
over 560 days without a case. In both cases the patients had MRSA on their skin when they
arrived in hospital. Despite our best attempts to decolonise them (treatment to remove skin
contamination) we were unable to prevent a bacteraemia.
The North East Quality Observatory System benchmark data reports the Trust at 0.00*
cases of MRSA bacteraemia per 1,000,000 bed days compared to a national mean of
11.10*.
*Data correct as of autumn v6.0 Acute Trust Quality Dashboard – period Q2 2012-13
MRSA Bacteraemia (April 2006 - March 2013)
24
22
20
18
16
14
12
10
8
6
4
2
0
2006/2007
2007/2008
2008/2009
2009/2010
Hospital acquired total
Year
2010/2011
2011/2012
2012/2013
Community acquired total
2006/2007
2007/2008
2008/2009
2009/2010
2010/2011
2011/2012
2012/2013
Hospital acquired total
22
16
9
5
4
0
2
Community acquired total
14
12
3
6
4
1
6
Quarter
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
Hospital acquired
4
8
7
3
6
2
6
2
5
0
3
1
2
2
1
0
0
0
3
1
0
0
0
0
0
0
2
0
Community acquired
5
4
3
2
3
4
2
3
0
1
2
0
3
2
0
1
1
0
3
0
0
0
0
1
2
3
0
1
The trend over the last seven-years can be seen in the graph and table above.
50
Annual Quality Account 2012-2013
2. Summary Hospital-level Mortality Indicator (SHMI)
The SHMI indicator provides an indication on whether the mortality ratio of a provider is
as expected, higher than expected or lower than expected when compared to the national
baseline in England.
SHMI mortality data should be reviewed against other sources of mortality data including
Hospital Standardised Mortality Ratio (HSMR).
SHMI includes deaths up to 30 days after discharge and does not take into consideration
palliative care. Although the Trust SHMI has remained within the as expected range at 110,
the Trust has undertaken a comprehensive review of cases to help understand where and why
deaths outside of hospital occur.
This review demonstrates that there are a high number of patients who have been discharged
home to die in accordance with their wishes and this has affected the hospital SHMI score.
The Trust is working with commissioners to review pathways of care and support patient
choice of residence at end of life wherever possible.
The data below has been taken from the Acute Trust Quality Dashboard v6.00.
The other Trusts identified are from the north east, and have been anonymised.
Summary
Hospital-level
Mortality
Indicator
(SHMI) Emergency &
Elective
RY
Q1
1213
National
Mean
North
Tees
Trust
1
Trust
2
Trust
3
Trust
4
Trust
5
Trust
6
Trust
7
100
110.50
98.70
108.50
93.60
104.10
104.60
101.30
92.30
Summary Hospital-level Mortality Indicator (SHMI)
Emergency & Elective
115.00
110.00
105.00
100.00
95.00
90.00
85.00
80.00
North Tees &
Hartlepool
Trust 1
Trust 2
Trust 3
Trust 4
Trust 5
Trust 6
Trust 7
Summary Hospital-level Mortality Indicator (SHMI) - Emergency & Elective
National Mean
3. Medication errors
Between April and February 2013, staff reported 527 medication related incidents across
hospital and community services of which 472 originated within the Trust. Some of these will
have been actual incidents and some will have been near misses. A near miss is the name
for a situation when the error did not actually happen but the circumstances were such that
there was potential for an error.
In the 2011-2012 Quality Accounts, it was reported that 372 medication related incidents
across hospital and community services.
Medication errors can happen at a number of steps in the process for example, when the
medication is prescribed, when it is dispensed by pharmacy, or when it is administered to
the patient. Annual Quality Account 2012-2013
51
There are many thousands of contacts made by our hospital and community teams every day.
We estimate there could be around 12 million staff interactions with medications during a
year which results in a very low risk of error when the reported incidents are considered
against the proportion of:
•The number bed days (around 400,000);
•The number of drugs a patient might be given, possibly five different drugs three or four
times a day;
•The steps in the process (prescribing, dispensing and administration).
We have a culture of encouraging all staff to report actual medication errors as well as
opportunities for error. The figures above show that our staff are doing an excellent job and
that patient safety is paramount.
The reason for encouraging reporting is not to look for blame; it is very much about
understanding why these rare things happen, learning from them and putting in systems
which will improve things in the future.
Actions taken by the Trust:
We have undertaken a number of actions this year to further raise awareness of opportunity
for medication errors.
The pharmacy department increased the number of ward based pharmacists. It also increased
the number of wards operating the system of Patient Orientated Pharmacy (POP). Both
of these allow the early identification of drug interactions and dosing errors by pharmacy
staff working closely with patients, nursing and medical staff. Additionally the POP service
increases patient safety as medication is administered from individual patient lockers reducing
the risk of incorrect selection of medication.
The Education and Organisation Development Directorate and pharmacy are working
together to ensure that all staff involved with the prescribing or administration of medicines
receive ongoing, evidence based training to allow them to practice safely. In the last year
we have revised the training needs analysis to ensure all staff groups who are involved in
medicines management receive appropriate training. We have introduced mandatory
training for all new staff involved in preparation, prescribing or administration of injectable
medicines. E-learning packages and workbooks have been developed to ensure multiple
access points are available for training. In depth audit and training programmes have been
introduced to areas such as paediatrics and antibiotic prescribing.
The Community Directorate has developed a competency based proficiency tool to support
staff involved in medication errors including lessons learnt.
Our positive reporting culture enables staff to understand what contributes to actual or
potential error and helps them to come up with solutions to continually review and reduce
risk. This is the reason why we have checks and balances in place across the Trust to improve
patient safety and to help our staff in any situation, whether they are caring for patients in
our hospitals or in the community.
The latest benchmarking data published by the North East Quality Observatory System
demonstrates that the Trust rate of medication errors is 42.5% lower than the national
mean rate with 4.12* per 1,000 bed days against a national rate 7.17*.
*Data correct as of autumn v6.0 Acute Trust Quality Dashboard – period Oct11- Mar12.
52
Annual Quality Account 2012-2013
4. Safety Thermometer
The Trust contributes to the Safety Thermometer which reports on four areas of harm:
•Pressure ulcers;
•Patient falls;
•Catheter acquired urine infection;
•VTE.
The Trust has been in discussion with the national leads due to problems relating to data
upload and accuracy. We continue to submit data for our wards and community services;
however we continue to have concerns about the validity of data.
The Trust currently triangulates different sources of pressure ulcer data in order to provide an
accurate reflection of performance.
Safety Thermometer data shows regional benchmarking data for the Trust in relation to new
pressure ulcers as follows: as far as we are aware, we are only one of a small number of
Trusts nationally who include community data with hospital data, which makes it difficult
to accurately compare results.
Pressure
Ulcers
- All
Pressure
Ulcers
- New
Falls
with
harm
UTI +
Catheter
All VTEs
*North Tees & Hartlepool (inc. community data)
5.88%
1.71%
1.93%
1.93%
7.34%
Trust 1
5.34%
1.07%
0.72%
1.19%
2.34%
Trust 2
8.30%
1.54%
1.22%
0.86%
0.30%
Trust 3
6.35%
0.96%
1.44%
2.99%
7.57%
Trust 4
5.97%
2.42%
0.94%
1.07%
1.53%
Trust 5
3.02%
1.28%
0.21%
0.74%
2.15%
National Averages
5.34%
1.20%
1.03%
1.12%
2.87%
*North Tees and Hartlepool NHS Foundation Trust include hospital and community data.
Pressure Ulcers from the Acute Trust Quality Dashboard v6.00
Incidence
of patients
with
pressure
ulcers per
1,000
admissions
Sep-12
National
Mean
North
Tees &
Hartlepool
Trust
1
Trust
2
Trust
3
Trust
4
Trust
5
Trust
6
Trust
7
NE
SHA
3.65
2.56
1.61
5.24
1.05
8.22
6.89
2.66
2.03
3.08
Data from the Acute Trust Quality Dashboard v6.00 identifies the Trust as a positive outlier
against the national mean in relation to pressure ulcers. The reason for the differences in
these two data sets is likely to be due to the fact that Safety Thermometer data includes
community data as hospital data. The Acute Trust Quality Dashboard measures only
hospital data.
53
Annual Quality Account 2012-2013
Venous Thromboembolism
VTE Related Readmission Rate
The Healthcare Evaluation Data (HED) dataset identifies the Trust as one of the top three
performers in the North East, in relation to the number of patients who are readmitted to
hospital due to a VTE. The Trust has a consultant led committee that provide leadership and
monitoring of VTE.
0.16%
0.14%
0.12%
0.1%
0.083%
0.08%
0.06%
0.04%
0.02%
0%
North East Trusts
North Tees and
Hartlepool NHS
Foundation
Trust
Data taken from 2011-2012 Q3 and Q4, 2012-13 Q1 and Q2 (Year reporting period)
5. Safeguarding
Adult Safeguarding
The Trust has delivered Passionate about Adult Safeguarding training on a monthly
basis during 2012-2013. These are innovative and intensive week long training events that
combine workshops covering key topics. This is open to all Trust staff as we recognise that
each of us plays a valuable role in Adult Safeguarding.
Every member of staff is provided with an Adult Safeguarding card which contains the
contact numbers to raise any adult safeguarding alerts and for the independent mental
capacity advocate service.
The Trust is raising awareness amongst staff and the public through displays and
communication campaigns.
The following table reflects the number of staff currently trained in the following categories:
Mental capacity staff training
Deprivation of liberty safeguarding (DOLS)
People With Learning Difficulty (PWLD)
Adult Safeguarding
Individual bespoke training
54
Annual Quality Account 2012-2013
131 staff
71 staff
102 staff
77 staff
265 staff
Children’s safeguarding
The Trust has continued to deliver on all key performance indicators relating to children’s
safeguarding and has received significant assurance from external agencies including Audit
North and multi agency OFSTED review in Hartlepool.
We have implemented a new in-house safeguarding children training programme, which
enables us to deliver targeted training to meet the needs of the organisation and maintain
high levels of compliance with standards.
Young people who helped the children’s safeguarding team produce e-safety posters.
Our Trust has a seat on all three Local Safeguarding Children’s Boards (LSCBs) – Hartlepool,
Stockton-on-Tees and County Durham and we continue to provide assurance through Section
11 of the Children’s Act that we are discharging our statutory responsibilities.
Section 11 of the Children’s Act provides a statutory framework for arrangements to
promote the welfare of children, the Trust's safeguarding for children operation group audits
performance in relation to statutory guidance.
Safeguarding
There are a number of examples of excellent development work being undertaken. One
example is the development of an adult risk behaviours assessment tool which has been
introduced in A&E/Urgent care. The purpose of this tool is to identify potential safeguarding
concerns when an adult presents with a behaviour which may impact on their ability to
parent (domestic abuse, substance misuse).
The Trust continues to ensure that safeguarding children and adults is a key priority and
closely monitors standards.
55
Annual Quality Account 2012-2013
Effectiveness of care
1. Pulmonary embolism (PE) or deep vein thrombosis (DVT) following surgery.
Dr Foster reporting period – February 2012 to January 2013 (rolling 12 month period of
latest data).
The rate of PE or DVT is above the national average value of 100. The expected number of
incidents over this time period was 30.90 and the Trust has had 36, giving a Relative Risk (RR)
of 116.40.
See chart and graph below:
Cases of PE or DVT
following surgery
Observed
Expected
Relative risk
Low
High
36
30.90
116.40
81.50
161.10
1,000
Relative Risk
800
600
400
200
0
20
40
60
80
100
120
Expected Deaths
*Data taken from Dr Foster
2. Post-op Haemorrhage or Haematoma.
Cases of haematoma (bruise) or haemorrhage (bleed) requiring a procedure following
surgery, Dr Foster reporting period – February 2012 to January 2013 (rolling 12 month period
of latest data).
The rate of Post-op haemorrhage or haematoma for the Trust is well below the national
average value of 100. The Trust is one of the best performers in the country.
The expected number of incidents over this time period was 10.33 and the Trust has had 3,
giving a Relative Risk (RR) of 29.05.
See following chart and graph:
Observed
Cases of haematoma
or haemorrhage
requiring a procedure
following surgery
56
Annual Quality Account 2012-2013
Expected
3
10.33
Relative risk
29.05
Low
High
5.84
84.49
1,000
Relative Risk
800
600
400
200
0
10
20
Expected Deaths
30
40
*Data taken from Dr Foster
3. Selected quality performance indicators and national benchmarks from the
North East Quality Observatory System (NEQOS)
NEQOS collects benchmark data on Trusts for a number of clinical indicators. The following
indicators provide an indication of Trust performance when compared to other NHS Trusts
nationally.
2012/13
2011/12
Effectiveness indicator
Date
Trust
value
National
Mean
Trust
Values
95th percentile wait for elective inpatient treatment (weeks)
Nov-12
20.80
21.30
18.10
Median wait for elective inpatient treatment (weeks)
Nov-12
9.61
8.73
8.77
Delayed transfer of care per 1,000 occupied beds –
NHS responsibility
Q2 12/13
783.10
669.50
21.20
% of all admissions who have had venous thromboembolism risk
assessment
Sep-12
91.60%
93.90%
94.40%
Medication errors per 1,000 bed days
Oct 11Mar 12
4.12
7.17
3.29
Admitted patient care - % valid data (average for all fields)
Nov-12
98.80%
98.11%
99.10%
Outpatient - % valid data (average for all fields)
Nov-12
91.00%
95.87%
91.40%
Accident and emergency - % valid data (average for all fields)
Nov-12
99.70%
97.44%
99.90%
Admitted patient care - % records submitted with valid HRG on
first submission
Oct-12
99.00%
96.80%
99.80%
Staff recommendation of the Trust as a place to work
(last CQC survey)
2011
54.60%
52.40%
61.80%
Staff recommendation of the Trust as a place to receive treatment
(last CQC survey)
2011
63.10%
62.80%
65.60%
Overall medical trainees global satisfaction score (last GMC survey)
2012
83.10%
78.60%
78.70%
Consultant clinical supervision trainers given to their trainees
2012
91.60%
86.80%
66.40%
*Information taken from Release 6.00 Winter 2012-2013. 2011-2012 data taken from the 2011-2012 Quality Report
4. The Integrated Professional Nursing and Midwifery Board (IPNMB)
We believe that we are the first hospital and community professional board of this type in the
country. The IPNMB is chaired by the Director of Nursing, Patient Safety and Quality.
Membership includes senior nursing and midwifery leaders from across both acute and
community settings: working collaboratively at a strategic level relating to professional,
operational and clinical developments and pathways. This board oversees strategy,
standards and assurances in relation to delivery of high quality nursing and midwifery care.
Annual Quality Account 2012-2013
57
All graduate profession: The Trust is committed to ensuring that all mentors in practice
are prepared for the delivery of the all graduate nurse education programmes. Development
of a practice passport, issued to all nurses, midwives and health visitors will enable mentors
to record their progress, continuous professional development and provide evidence of
meeting the required Nursing and Midwifery Council (NMC) Standards.
In September 2012, the Chief Nursing Officer (CNO) for England and the Department
of Health Nurse Director provided an opportunity to create a new national strategy for
nursing and midwifery by inviting discussion on a consultation to develop a culture of
compassionate care, creating a vision for nurses, midwives and caregivers. This vision is
underpinned by six fundamental values: (referred to as the six Cs)
•Care
•Compassion
•Competence
•Communication
•Courage
•Commitment
There are six areas of action to support professionals to deliver excellent care. Taking a
leading edge, these fundamental values will be integrated into both the Trust Nursing and
Midwifery Strategy and be adopted by all Trust staff.
In 2009, the Trust introduced its modern apprentice scheme; this two year programme
delivered in partnership with local further education colleges provides the Trust with an
opportunity to ensure that unregistered staff have the skills, knowledge and values
acquired to be part of our nursing team.
This scheme has been recognised by the CNO for England.
Midwifery assistant Ruth Waterman.
58
Annual Quality Account 2012-2013
Patient experience
1. You're welcome
You're Welcome is a Department of Health quality criteria for young, people friendly, health
services which the Paediatric service are participating in. The service will be assessed by a
panel including young people, of their provision within nine topical areas:
6. Accessibility
7. Publicity
8. Confidentiality and consent
9. Environment
10.Staff training, skills, attitudes and values
11.Joined-up working
12.Young people’s involvement in monitoring and evaluation of patient experience
13.Health issues for young people
14.Sexual and reproductive health services
2. People with Learning Disabilities
The Trust held successful events in September 2012 and December 2012. These events were
focused on the broad issues of protecting those most vulnerable in our communities. Post
Winterbourne View Interim Report prompted us to commission the performance Out of
Sight, which is an interactive drama which was produced and performed by Operating
Theatre. The December 2012 event also promoted the recently adopted 'Deciding Right'
approach to advance decisions about end of life choices.
Hospital Tours for people with learning disabilities have been introduced in 2012 across
both the sites and are proving to be a success.
Every ward has been provided with a copy of the Winterbourne View Interim Report as part
of their learning resource files.
Learning resource files have been developed during 2012 and are in place as a support tool
to dealing with people with learning disabilities. MCA, MHA and DoLS codes of practice and
posters have been distributed for quick reference.
We have updated the Learning Disability Pathways of Care and will continue to refine this
in 2013.
We have strengthened the Trust's People with Learning Disabilities Strategy Group and this
includes people with LD.
The Board of Directors have been updated in relation to the Francis Report, Winterbourne
View report, Airedale report, Six Lives report, Care Ombudsman report and recently have
been briefed on the Savile enquiry.
Winterbourne review – Easy Read version
www.wp.dh.gov.uk/publications/files/2012/12/easy-read-of-final-report.pdf
The Trust hosted multi agency conferences in Hartlepool to highlight its 'Passionate About
Safeguarding Work'. Over 300 people attended and provided excellent feedback.
59
Annual Quality Account 2012-2013
3. Pressure ulcers (also known as decubitus ulcer or pressure sores)
Reducing opportunity for pressure ulcers has been a high priority for all healthcare staff in the
community and in hospital. (See section 3, Patient Safety point 4)
Actions taken by the Trust:
Over the year, training in the prevention and management of pressure ulcers has been
further enhanced. Every pressure ulcer graded as category two, three or four that is acquired
whilst in our care is subject to a full investigation to help us to understand whether it was
avoidable or not and importantly, whether there is anything that we can learn. At the end
of 2011-2012 a new body-mapping process was introduced. This should be completed
on admission to hospital or admission onto a district nursing caseload. It is also completed
on discharge from hospital for all patients who have a wound and the information passed
onto the next care provider. The IPNMB oversee actions to pursue continuous improvement in
performance.
Bi-annual pressure ulcer prevalence audits are carried out across both the hospital and
community services. Our specialist nurses support bespoke training and support clinical teams
to maximise treatment options. In 2013-2014, we will continue to focus on the reduction of
avoidable pressure ulcers in hospital and in the community setting. At the end of 2012-2013
a new care bundle is to be introduced. The SSKIN (Surface, Skin inspection, Keep moving,
Incontinence, and Nutrition) bundle focuses on interventions proven to reduce the risk of
pressure ulcers occurring.
The Trust participated in a research study ending in 2011 to assist the development and
validation of a patient reported outcome measure of health related quality of life for patients
with pressure ulcers (PUQOL). This was part of a programme of research and the team have
submitted an expression of interest to be a recruiting site for a further two research studies to
commence in 2012.
The Pressure Ulcer Quality of Life Adjusted Years (PUQALY) is a small sample study of patients
with pressure ulcers and involves the completion of a nurse administered questionnaire.
The Pressure 2 trial proposes to compare high specification foam mattresses and alternating
pressure mattresses for patients at high risk of pressure ulcers in hospital settings.
It is anticipated portfolio studies will commence in early 2013 with funding support for
research nurse input from the CLRN.
60
Annual Quality Account 2012-2013
How did we do?
Dr Foster data for February 2012 to January 2013 (rolling 12 month period of latest data)
demonstrates that the Trust is similar when benchmarked nationally in relation to rate of
hospital acquired decubitus ulcers in patients discharged from surgical and medical wards/
departments. The relative risk is 104.86, which means that for 100 patients that acquire a
pressure ulcer in the average hospital in England, 104.86 patients acquire one in our care.
Observed
Cases of decubitus
ulcer amongst surgical
or medical discharges.
Expected
252
Relative risk
240.31
Low
104.86
High
92.31
118.64
1,400
1,200
Relative Risk
1,000
800
600
400
200
0
1
201
401
Expected Deaths
Dr Foster data for January-December 2011 (reported in the 2011/2012 Quality Report),
demonstrates that the Trust performs well nationally. The relative risk of acquiring decubitus
ulcers in patients discharged from surgical and medical wards/departments is 84.40; this
means that for 100 patients that acquire a pressure ulcer in the average hospital in England,
84.4 patients acquire one in our care.
NB: Data obtained from Dr Foster and the 2011/2012 Quality Report.
4. Spiritual and emotional care of patients at the end of their life
In November 2011, the National Institute of Health and Clinical Excellence (NICE) published
guidance describing the importance of spiritual and religious support to patients approaching
end of life. The guidance specifically referred to the role of chaplains in end of life care.
We were very pleased to read the guidance because it promotes the approach that our Trust
has taken since July 2009 to meet the needs of patients and families when faced with the
knowledge that end of life is near.
Actions taken by the Trust:
Since July 2009, this Trust has routinely referred patients on the end of life care pathway
to the chaplaincy team. During 2012-2013, 713 patients were referred by our staff to this
pioneering service provided by the Trust chaplains. They provide spiritual, pastoral and
emotional support to patients, families and staff. Only 14 patients declined their support
during the year. 396 patients welcomed and received multiple visits. This service offers
added value to the quality of overall care provided to patients and their loved ones and has
highlighted the importance of this aspect of support to the dying patient.
This innovative and groundbreaking approach has been recorded for national television and
featured in publications.
Annual Quality Account 2012-2013
61
This initiative has been so successful that in August 2012, the service was extended into the
community. We received funding to run a pilot over 18 months to address the spiritual and
pastoral needs of patients in the community. Initially, this was for patients on or near the end
of life, but practice has indicated that the service needs to be offered to patients earlier in the
palliative care stage, in order to build up a relationship with the patient and offer a meaningful
service. Perhaps because of management restructuring in the community, referrals have been
less frequent than in the acute trust, but they are now beginning to gather momentum.
When this service is allied to the use of the Family’s Voice (carers diary), we believe that our
philosophy of care results in a better experience for patients, relatives and carers as well as
better job satisfaction for clinical staff and chaplains.
The following chart and table provides data relating to chaplain referrals:
Chaplain Referrals, Received more than 1 visit and Declined Support
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
Jan-12
Feb-12
Mar-12 Apr-12 May-12 Jun-12
Referrals
Jan12
Feb- Mar12
12
Jul-12
Aug-12
Sep-12
Oct-12 Nov-12 Dec-12
Received more than 1 visit
Apr- May12
12
Jun12
Jul- Aug12
12
Jan-13
Feb-13
Mar-13
Declined Support
Sep12
Oct- Nov12
12
Dec12
Jan13
Feb- Mar13
13
Referrals
52
51
47
62
54
48
64
46
53
64
57
48
68
51
50
Received
more than
1 visit
35
34
28
37
33
30
42
4
8
41
43
21
41
25
27
2
2
0
4
1
0
1
0
0
2
1
0
1
1
0
Declined
Support
5. Formal complaints and compliments
Actions taken by the Trust:
The Trust continues to work hard to improve customer satisfaction through patient experience.
In 2009-2010 we started to record the number of compliments received. The number of
thank you and complimentary comments has increased year on year. Trends in complaints
and compliments can be seen in the table below.
We do recognise that we don’t always get things right and this is why we have a dedicated
patient relations team to listen to and investigate any concerns or complaints.
We continue to work hard to provide high standards of clinical care delivered with dignity
and compassion for everyone. Feedback from patients is important because it helps us to
understand what we do well and what we can improve further.
62
Annual Quality Account 2012-2013
How did we do?
The number of formal complaints received over the last four-years is shown in the table below:
Year
Complaints
Compliments
2009
2010
2011
2012
358
341
371
396
2,212
3,786
5,087
5,414
External feedback
The North East Quality Observatory System benchmark data reports the Trust at 3.69*
written complaints per 1,000 episodes of care, which is significantly lower than the
national mean of 4.43*.
*Data correct as of autumn v6.0 Acute Trust Quality Dashboard – period Q1 2012-13
In 2013 the CQC undertook an unannounced review of services which included Outcome
16: Assessing and monitoring the quality provision. The full CQC report describes the
observations and evidence reviewed. The CQC provided positive feedback regarding the
numerous ways the Trust evaluates patient care and reported that any issues raised or
complaints made by people had been dealt with promptly and appropriately.
North East Quality Observatory System reports (2010-2011), for inpatient experience
measure for the Trust as 7.60* against a national mean score of 7.40*.
*Data correct as of autumn v6.0 Acute Trust Quality Dashboard – period 2010/11
6. Sensory loss
In response to feedback from patients with sensory loss the Trust has delivered a targeted
campaign to ensure a focus on quality of experience for people with disability.
This work is ongoing. During 2012 progress was made in the following areas:
•Scoping all wards and department across both hospital sites to look at the facilities for
people with sensory loss and/or impairment;
•Work with audiology/ophthalmology to establish best practice and recommend equipment
and facilities for use on wards;
•Develop a standard range of equipment to be available on all wards in 2013;
•Develop sensory loss awareness training;
•Re-establish the mobile phone function for people with hearing loss into the Patient
Relations department;
•Review and renew leaflets and resources in use for supporting patients with sensory loss
impairment;
•Support and influence the Trust Equality and Diversity Working Group and its action plan;
•Work with Teesside Safeguarding Vulnerable Adults in Hospital Group to ensure admission
and discharge processes are sensitive to the needs of patients with sensory loss impairment
and reasonable adjustments are highlighted;
•Involve people with sensory loss in work streams.
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Annual Quality Account 2012-2013
7. PROMS
The Trust participated in the original pilot for PROMS, and as such, this is well embedded into
practice with high numbers of returns for our patients admitted via elective pathways for hip,
knee replacement, hernia repair and varicose vein surgery. The Trust has been identified as
an outlier in relation to hips. In response it has undertaken a comprehensive review of hips
PROMS cases and has established that, patients score positively in relation to the outcome of
their operation; however patients are scoring less positively in their general health. A review
of case notes has identified that the low score relates to overall health and not to the surgery
itself in the majority of cases.
The following table reflects the four PROMS measures compared with the other North
East Trusts:
Acute Trust Quality Dashboard
(Nov v6.0)
Trusts
National
Mean
IH23
IH24
IH25
IH26
Patient Reported
Outcome Measure - %
Patients reporting an
improvement following
hip replacement
(Apr 11-Mar 12)
1112
Patient Reported
Outcome Measure - %
Patients reporting an
improvement following
knee replacement
(Apr 11-Mar 12)
1112
Patient Reported
Outcome Measure - %
Patients reporting an
improvement following
varicose
vein procedure
(Apr-Jun 12)
1213
Patient Reported
Outcome Measure - %
Patients reporting an
improvement following
hernia procedure
(Apr-Jun 12)
1213
Annual Quality Account 2012-2013
Trust 2
Trust 3
Trust 4
Trust 5
Trust 6
Trust 7
87.00%
83.90%
86.90%
87.10%
88.50%
89.50%
78.60%
83.00%
88.00%
78.70%
82.10%
81.00%
58.30%
79.80%
81.00%
78.50%
78.50%
82.00%
39.20%
NO DATA
NO
DATA
NO
DATA
58.10%
NO
DATA
0.00%
NO
DATA
44.40%
46.00%
45.00%
33.30%
54.50%
45.50%
53.80%
39.10%
62.50%
57.10%
*Data taken from the Acute Trust Quality Dashboard v 6.0
64
North
Tees & Trust 1
Hartlepool
Part 3B: Performance from key national priorities from
the Department of Health Operating Framework,
Appendix B of the Compliance Framework
The Trust continued to deliver on key cancer standards throughout the year; two week
outpatient appointments, 31 days diagnosis to treatment and 62 day urgent referral to
treatment access targets. The Trust demonstrated a positive position with evidence of
continuous improvement against the cancer standards introduced in the Going Further with
Cancer Waits guidance (2008).
www.connectingforhealth.nhs.uk/nhais/cancerwaiting/cwtguide7.pdf
The compliance framework forms the basis on which the Trust's Annual Plan and in year
reports are presented. Regulation and management of these remain paramount in the
Trust to ensure patient safety is considered in all aspects of operational performance and
efficiency delivery. The current performance against national priority, existing targets and
cancer standards are demonstrated in the table below with comparisons to the previous year.
Existing commitments
4 hour emergency care target
National
Standard
Performance
2012-13
Performance
2011-12
Achieved
95%
97%
98.13%
√
In patient waiting time
26 weeks
0
0
√
Out patient waiting time
13 weeks
0
0
√
100%
100%
100%
√
Year on year
improvement
40%
0.29%
√
Readmission within 28 days of non
medical cancellation
100%
100%
100%
√
Delayed transfers of care
3.50%
2.09%
2.43%
√
18 weeks maximum wait referral to
treatment (RTT)- admitted pathways
90%
92.53%
94.07%
√
RTT 95th percentile wait – admitted
pathways
23 weeks
20.6 weeks
19 weeks
√
95%
99.25%
99.22%
√
RTT 95th percentile wait – non admitted
pathways
18.3 weeks
11.9 weeks
11.6 weeks
√
18 weeks maximum wait referral to
treatment (RTT) – incomplete pathways
92%
(Operating
Framework
2012-13)
96.75%
97.16%
√
28 weeks
16.94 weeks
16.6 weeks
√
MRSA (post 48 hours)
1
2
0
X
C dIff (post 48 hours)
44
61
68
X
0
0
0
√
Full
Compliance
Full
Compliance
√
Access to rapid access chest pain clinics
within 2 weeks of referral from GP
Cancelled operations for non medical
reasons
18 weeks maximum wait referral
to treatment (RTT) - non admitted
pathways
RTT 95th percentile wait – incomplete
pathways
Eliminating mixed sex accommodation
Compliant with access to healthcare for
patients with learning disabilities
65
Annual Quality Account 2012-2013
Cancer standards
National
Standard
Performance
2012-13
Performance
2011-12
Achieved
14 day maximum wait for a first
outpatient appointment following
urgent GP referral
93%
95.4%
93.58%
√
14 day maximum wait for a first
outpatient appointment for breast
symptomatic referral
93%
92.6%
94.71%
X
31 day maximum wait to decision to
treat
96%
99.4%
99.25%
√
31 day maximum wait decision to treat
to subsequent treatment (drug therapy)
98%
99.8%
100%
√
31 day maximum wait decision to treat
to subsequent treatment (surgery)
94%
98.3%
95.91%
√
62 day maximum wait referral to
treatment - all cancers
85%
88.1%
88.20%
√
62 day maximum wait from screening
recall to treatment
90%
94.1%
95.76%
√
Criteria for 62 day cancer wait:
The indicator is expressed as a percentage of patients receiving first definitive treatment for
cancer within 62 days of an urgent GP referral for suspected cancer.
An urgent GP referral is one which has a two week wait from date that the referral is received
to first being seen by a consultant.
The indicator only Includes GP referrals for suspected cancer (i.e. excludes consultant upgrade
and screening referrals and where the priority type of the referral in National Code 3 - Two
week wait).
The clock start date is defined as the date that the referral is received by the Trust. The clock
stop date is the date the first definitive cancer treatment as defined in the NHS Dataset Set
Change Notice (day of the year, not 24 hour periods).
To note: Cancer Standards position was not finalised at time of print.
Part 3C: Department of Health Core Indicator Set
The data for all nine indicators has been taken from the NHIS IC indicator portal.
1. Summary Hospital-level Mortality Indicator (SHMI) - Deaths associated with
hospitalisation, England, October 2011-September 2012
The North Tees and Hartlepool NHS Foundation Trust considers that this data is as
described for the following reason. SHMI mortality data when reviewed against other
sources of mortality data including Hospital Standardised Mortality Ratio (HSMR) and when
benchmarked against other NHS organisations will provide a robust overview of overall
mortality performance.
The North Tees and Hartlepool NHS Foundation Trust has taken actions to improve
this score, the quality of its services, by undertaking a comprehensive review of cases to help
understand where and why deaths within 30days of discharge occur.
Work to understand SHMI is described in public board reports and in Part 2 of this document.
The SHMI indicator provides an indication on whether the mortality ratio of a provider is
as expected, higher than expected or lower than expected when compared to the national
baseline in England.
66
Annual Quality Account 2012-2013
SHMI includes deaths up to 30 days after discharge and does not take into consideration
palliative care. Although the Trust SHMI has remained within the as expected range at 1.08
it is higher than HSMR.
Provider
National Average
Trust Value
OD Banding
1.00
1.08
2
National Average
Trust Value
OD Banding
Highest SHMI Trust Value in the country
1.00
1.21
1
Lowest SHMI Trust Value in the country
1.00
0.68
3
North Tees and Hartlepool Nhs Foundation Trust
Provider
NB: Data from the Health and Social Care Information Centre (HSCIC).
OD banding descriptions:
OD banding 1 - higher than expected
OD banding 2 - as expected
OD banding 3 - lower than expected
2. Percentage of deaths with palliative care coding, Oct 2011 - Sept 2012
21.60% of patients that die in or within 30 days of discharge from the Trust are coded as
patients receiving palliative care. This has been evidenced through the SHMI mortality review
and reported to the board.
The benchmark data identifies the Trust as having a higher proportion of patients receiving
palliative care admitted to hospital than many other organisations in the North East and
significantly more than the average across the hospitals in England.
Provider
Diagnosis Rate
Combined Rate
North Tees And Hartlepool NHS Foundation Trust
21.60
21.60
South Tees Hospitals NHS Foundation Trust
15.70
15.70
South Tyneside NHS Foundation Trust
20.60
26.90
The Newcastle Upon Tyne Hospitals NHS Foundation Trust
19.40
19.40
Northumbria Healthcare NHS Foundation Trust
24.00
24.30
Gateshead Health NHS Foundation Trust
13.20
13.60
County Durham And Darlington NHS Foundation Trust
13.20
13.20
City Hospitals Sunderland NHS Foundation Trust
11.50
11.50
National Average
19.00
19.20
National Highest and Lowest Trust Diagnosis Rates
Provider
Diagnosis Rate
Combined Rate
Highest Trust Diagnosis Rate in the country
43.30
43.30
Lowest Trust Diagnosis Rate in the country
0.20
0.20
NB: Data from the Health and Social Care Information Centre (HSCIC).
The latest data available to the Trust for the reporting year (01 April 2012 – 31 March 2013)
relating to the palliative care coding is as follows:
14.84% of patients that die in or within 30 days of discharge from the Trust are coded as
patients receiving palliative care.
67
Annual Quality Account 2012-2013
3. PROMS; patient reported outcome measures.
The North Tees and Hartlepool NHS Foundation Trust considers that this data is as
described for the following reasons. The Trust has been identified as an outlier in relation
to hips.
The North Tees and Hartlepool NHS Foundation Trust has taken the following actions
to improve this score, and so the quality of its services, by undertaking a comprehensive
review of hips PROMS cases and has established that, patients score positively in relation
to the outcome in related to their operation; however patients are scoring less positively in
their general health. A review of case notes has identified that the low score relates to overall
health and not to the surgery itself in the majority.
The Trust participated in the original pilot for PROMS, and as such, this is well embedded into
practice with high numbers of returns for our patients admitted via elective pathways for hip,
knee replacement hernia repair and varicose vein surgery.
North Tees and Hartlepool NHS Foundation Trust
PROMS Procedure Group
National Average
Adjusted average
health gain
Groin hernia
0.090
0.052
Varicose vein
0.089
No Data
Hip replacement
0.429
0.392
Knee replacement
0.321
0.326
Highest and Lowest National health gain Trust scores
National Average
Highest adjusted
average health gain
Lowest adjusted
average health gain
Groin hernia
0.090
0.153
0.017
Varicose vein
0.089
0.138
0.027
Hip replacement
0.429
0.500
0.328
Knee replacement
0.321
0.408
0.201
PROMS Procedure Group
NB: Data from the Health and Social Care Information Centre (HSCIC) - April 2011 to December 2012 (published 9th
May 2013) – Provisional.
For additional information relating to PROMS see section 3A Patient Experience point 7.
April 2011 to December 2012 (published 9th May 2013) – Provisional.
4. Patients readmitted to a hospital within 28 days of being discharged.
The Trust is reported as having higher than average rates of readmission to hospital within 28
days of being discharged, as shown in the table below.
North Tees and Hartlepool NHS Foundation Trust – Medium Acute Trust
Age Group
Indirectly age, sex,
method of admission,
diagnosis, procedure
standardised percent
National
Average
Percent
improvement from
2009-10 to 2010-11
5 Band Comparison
against national
average
0 to 14
11.45
15 or over
11.48
10.15
6.38
A1
11.42
-2.23
W
*Data for 2010-11 standardised to persons 2006-07 (December 2012) NB: Data from the Health and Social Care
information Centre (HSCIC).
68
Annual Quality Account 2012-2013
Highest Indirectly age, sex, method of admission, diagnosis, procedure
standardised percent scores Trusts Nationally
Age Group
Indirectly age, sex, method of admission,
diagnosis, procedure standardised percent
5 Band Comparison against
national average
0 to 14
22.93
A1
15 or over
25.80
A1
Lowest Indirectly age, sex, method of admission, diagnosis, procedure
standardised percent scores Trusts Nationally
Age Group
Indirectly age, sex, method of admission,
diagnosis, procedure standardised percent
5 Band Comparison against
national average
0 to 14
0.00
B1
15 or over
0.00
B1
5 Band Comparison against national average
Note 1: National Comparison, based on 95% and 99.8% confidence intervals of
the rate
B1 = Significantly better than the national average at the 99.8% level;
B5 = Significantly better than the national average at the 95% level but not at the
99.8% level;
W = National average lies within expected variation (95% confidence interval);
A5 = Significantly poorer than the national average at the 95% level but not at the
99.8% level;
A1 = Significantly poorer than the national average at the 99.8% level.
Regular audits are undertaken to identify pathways for redesign and other initiatives are
being developed, tested and implemented, resulting in a better patient experience whilst
maintaining a safe, quality and efficient service.
The latest data available has been extracted from Dr Foster (February 2012 – October 2012)
which shows the following:
Readmisions (28 days)
Age Group
Actual
Expected
Difference between actual and expected readmisions
0 to 14
421
428.30
-7.30
15 or over
4528
4415.10
112.90
This demonstrates that the age group of 0-14 has fewer than expected readmissions whilst
the age group of 15 or over exceeds its expected readmissions.
The North Tees and Hartlepool Foundation Trust has taken the following actions
to improve this percentage, and so the quality of its services, by preventing avoidable
readmissions within 30 days of discharge has presented a considerable challenge for the
Trust and is being addressed by the investment of a significant amount of work and effort.
With the required focused clinical leadership and strategic approach there has been a marked
improvement to the elective and emergency readmission position.
A readmission strategy has been produced, patient pathways have been redesigned and
new initiatives implemented including: community integrated assessment teams and
teams around practices to ensure that patients receive timely care, at home, by the most
appropriate healthcare professional; the introduction of a dedicated cholecystectomy list
to provide timely access to surgery for patients who may have had recurrent admissions to
hospital with acute cholecystitis whilst awaiting a date for surgery; the implementation of
a single telephone access point to direct patients, carers and healthcare professional to the
most appropriate service to meet the needs of the patient; and the utilisation of ambulatory
care so that patients can be assessed, seen and treated by senior clinicians and return home
without the need for admission to hospital.
Annual Quality Account 2012-2013
69
5. Responsiveness to the personal needs of its patients, 2003/04 - 2011/12
(Financial year)
The Trust has worked hard in order to further enhance its culture of responsiveness to the
personal needs of patients.
The North Tees and Hartlepool NHS Foundation Trust considers that this data is as
described for the following reasons. The Trust has developed its Patients First strategy
and understanding patient views in relation to responsiveness, personal needs helps us to
understand how well we are performing.
The North Tees and Hartlepool NHS Foundation Trust has taken the following actions
to improve this score, and so the quality of its services, by delivering accredited programmes
that focus on responsiveness of patient and carers for both registered and unregistered
nurses. We use human factors training to raise awareness of the impact of individual acts
and omissions on patient outcomes and experience. When compared against the national
average score the Trust continues to be rated well by patients.
Period of
Coverage
National
Average
North Tees and Hartlepool
NHS Foundation Trust
Highest National
Trust Average
Weighted Score
Lowest National
Trust Average
Weighted Score
(out of 100)
(out of 100)
(out of 100)
2012-13
No Data
No Data
No Data
No Data
2011-12
67.40
71.00
85.00
56.50
2010-11
67.30
70.10
82.60
56.70
2009-10
66.70
65.70
81.90
58.30
2008-09
67.10
68.50
83.40
56.90
2007-08
66.00
66.30
83.10
54.60
2006-07
67.00
72.40
84.00
55.10
2005-06
68.20
72.80
82.60
55.80
2003-04
67.40
73.00
83.30
56.00
NB: Data from the Health and Social Care Information Centre (HSCIC).
In 2011-12 the National Average score for England in response to this question was 67.40%.
NB: Average weighted score of 5 questions relating to responsiveness to inpatients’ personal
needs (Score out of 100).
6. Recommend the Trust as a provider of care to their family or friends
The North Tees and Hartlepool NHS Foundation Trust considers that this data is as
described for the following reasons. The Family or Friends (F&F) test identifies the percentages
of patients who would recommend the Trust as a provider of care to their family or friends.
The North Tees and Hartlepool Foundation Trust has taken the following actions to
further improve this percentage, and so the quality of its services, by involving patients
relatives and staff in developing a strategy for care. Wards and the A&E department are
monitored in relation to the F&F test.
The Trust believes that the attitude of its staff is the most important factor in the experience
of patients. We will continue to work with staff to develop the leadership and role modeling
required to further enhance the experience of patients, carers and staff.
As part of our commitment to improve the service we provide, the Education & OD
department are currently working with patient facing staff to improve customer care.
The process starts with reminding staff of the Trust's vision along with the values and
behaviors required to achieve it. A customer care charter is then developed by the staff to
remind and encourage then to provide the highest care possible.
70
Annual Quality Account 2012-2013
National NHS Staff Survey 2012
Question: If a friend or relative needed treatment, would I be happy with the standard of
care provided by this Trust?
North Tees and Hartlepool NHS
Foundation Trust
Score
National
National NHS Staff Survey 2012
Highest Trust Score
Lowest Trust Score
60.619
94.199
35.337
NB: Data from the Health and Social Care Information Centre (HSCIC).
This data demonstrates that the Trust results are in line with the national average. The Trust is
working to improve this score for the future.
7. Risk assessed for Venous Thromboembolism
The North Tees and Hartlepool Foundation Trust considers that this data is as described
for the following reasons. Understanding percentage of patients who were admitted to
hospital who were risk assessed for VTE helps the Trust to understand and reduce cases of
avoidable harm.
The North Tees and Hartlepool Foundation Trust has taken the following actions to
continue to improve this percentage, and so the quality of its services, by including training
on the importance of VTE risks assessment at induction of clinical staff. Consultants monitor
performance in relation to VTE risk assessment on a daily basis.
The Trust has promoted the importance of doctors undertaking assessment of risk of VTE for
all appropriate patients in line with best practice.
North Tees and Hartlepool NHS Foundation Trust
Quarter
Number of VTEassessed Admissions
Total Admissions
Percentage of admitted
patients risk-assessed for VTE
National
Average
Q1
16,957
18,231
93.00%
93.40%
Q2
16,813
18,234
92.20%
93.80%
Q3
17,316
18,482
93.70%
94.10%
Q4
No Data Available
No Data Available
No Data Available
No Data Available
NB: Data from the Health and Social Care Information Centre (HSCIC).
Highest and Lowest percentage of admitted patients risk-assessed for VTE nationally
Quarter
Highest percentage of admitted patients
risk-assessed for VTE
Lowest percentage of admitted patients
risk-assessed for VTE
Q1
100%
80.80%
Q2
100%
80.90%
Q3
100%
84.60%
Q4
No Data Available
No Data Available
NB: Quarter 4 data not available at time of print.
71
Annual Quality Account 2012-2013
8. Rate per 100,000 bed days of cases of C diff infection reported within the
Trust amongst patients aged 2 or over.
Understanding the Trust's benchmark position in relation to C diff is important and informs
actions that can be taken to understand and reduce the burden of this infection.
The North Tees and Hartlepool Foundation Trust considers that this data is as described
for the following reasons. Understanding the Trusts benchmark position in relation to C
difficile is important and informs actions that can be taken to understand and reduce the
burden of this infection.
The North Tees and Hartlepool Foundation Trust has taken the following actions to
improve this rate, and so the quality of its services, by undertaking a comprehensive review of
all data in relation to C difficile, including not only the number of cases reported, but also the
number of samples sent for analysis. This provides evidence that the Trust is proactive in its
testing regime when compared to many organisations.
When compared to Trusts nationally the organisation is reported as an outlier:
April 2011 - March 2012
Rate per 100,000 bed-days for specimens taken
from patients aged 2 years and over
North Tees and Hartlepool NHS Foundation Trust
35.20
Highest National rate
51.60
Lowest National rate
0.00
National Average rate
21.80
NB: Data from the Health and Social Care Information Centre (HSCIC).
For more detail on C difficile see priority 1 patient safety section.
The latest position available to the Trust relating to the Rate per 100,000 bed days of
cases of C difficile infection reported within the trust amongst patients aged 2 or
over is as follows:
April 2012 - March 2013
Rate per 100,000 bed-days for specimens taken
from patients aged 2 years and over
North Tees and Hartlepool NHS Foundation Trust
29.98
*Data not validated at time of print.
9. Patient safety incidents reported within the Trust during the reporting period,
and the number and percentage of such patient safety incidents that resulted in
severe harm or death.
This indicator is expressed as a percentage of Patient Safety Incidents (PSI) reported to the
National Reporting and Learning Service (NRLS) that have resulted in severe harm or death.
The ‘degree of harm’ for PSIs is defined as follows:
•Severe – the patient has been permanently harmed as a result of the PSI;
•Death – the PSI has resulted in the death of the patient.
Reporting and understanding patient safety incidents is an important indicator of a safety
culture within an organisation.
72
The North Tees and Hartlepool Foundation Trust considers that this data is as described
for the following reasons. Understanding numbers and rate of incidents reported alongside
the percentage of deaths reported enables the organisation to understand whether actions
taken are effective.
Annual Quality Account 2012-2013
Medium Acute organisations - Organisational incident data by organisation in 6-month
period, April 2012 – September 2012.
Organisation Name
Total
Number of
Incidents
Rate
per 100
admissions
Severe
Harm
Incidents
Percentage
(%)
Death
Percentage
(%)
North Tees and Hartlepool
NHS Foundation Trust
2,615
6.27
17
0.70
1
0.00
Average across all Medium
Acute organisations
2,603
6.87
14.91
0.62
4.53
0.20
Highest and Lowest Trusts rate per 100 admissions
Trusts
Total Number
of Incidents
Rate per 100
admissions
Severe Harm
Incidents
Percentage
(%)
Death
Trust A - Highest
4,552
14.44
Trust B - Lowest
1,047
3.11
Percentage
(%)
61
1.30
15
0.30
5
0.50
2
0.20
NB: Data from the Health and Social Care Information Centre (HSCIC).
The North Tees and Hartlepool Foundation Trust has taken the following actions to
improve this reporting rate and so the quality of its services, by weekly monitoring if incidents
and actions taken to reduce risk of recurrence. The Trust also undertakes regular mortality
reviews and these are described within the Quality Account. The Trust remains proactive in its
review of incident reporting and its monitoring of impact of actions taken.
This proactive approach to patient safety has supported a reduction in deterioration and
serious harm, as is evidenced in part 2.
The latest data available to the Trust for the reporting year (1 April 2012 – 31 March 2013)
relating to the patient safety incidents that are reported to the National Reporting and
Learning Service (NRLS) are as follows:
The following incidents total does not include No injury, whilst the tables above reported by
the HSCIC does include No injury.
Trusts
Number of incidents
% of incidents
Low
Minor
Moderate
Severe Harm
Death
Total number of incidents
540
707
989
49
1
2,286
23.62
30.93
43.26
2.14
0.04
73
Annual Quality Account 2012-2013
Annex 1
Third Party Declarations from the Annual Quality Account
We have invited comments from our key stakeholders. Third party declarations from key
groups are outlined below:
Council of Governors (third party declaration – 4 March 2013)
This statement aims to provide evidence that the Governors of North Tees and Hartlepool
NHS Foundation Trust (the Trust) have been involved in the formation of the Trust’s Annual
Quality Account 2013-14. Governors were fully appraised regarding the Quality Account at
Council of Governors meetings throughout the year, and were provided with a wide range of
data and evidence covering all aspects of the Account’s content that was included in regular
update and performance reports presented by Directors. Governors are also kept updated
regarding service developments, and future visions, and have been able to contribute to
discussions regarding the refresh of the Trust’s Corporate Strategy via the Strategy Subcommittee, and development sessions at the Council of Governors meetings. In addition, a
working group of Governors assisted by the Assistant Director of Nursing, Quality and Patient
and Public Involvement was established, to discuss priority areas to be included in the Quality
Account, and to review the draft Account in detail on behalf of the Council of Governors,
seeking assurances/providing challenge regarding certain elements that required clarification.
The feedback obtained from these sessions helped shape the key priorities within the Quality
Account for 2013-14, and the final content.
At the Council of Governors development sessions during 2012-13 workshops took place
to provide Governors and the Board of Directors with an in depth insight and scrutiny of
priority areas from the Quality Account, including Dementia Care, and clostridium difficile.
The sessions allowed Governors to provide valuable feedback and suggestions regarding
work being undertaken in these areas, and also ensure that they are fully aware of both the
challenges being faced by the Trust, and the valuable improvements being made to patient
care. The Trust has recently experienced unprecedented levels of activity which has resulted
in increasing the North East Escalation Policy (NEEP) to level 3 and on one occasion to level
4. This is the agreed protocol between trusts to manage resilience. It means that the Trust is
experiencing service pressures and requires support from staff in all areas, both clinical and
non-clinical. The response by staff has been brilliant. The Board thanked staff for their hard
work and ensured that provisions were made for staff that were unable to leave clinical areas
for a break, and during the spell of bad weather, arrangements were made for staff that
were unable to travel home. Patient Safety and Quality continue to be areas of focus for the
Trust, and a Quality Report is provided at every Council of Governors and Board of Directors
meetings by the Director of Nursing, Patient Safety and Quality.
During 2012-13 the programme of Patient Experience Quality Standards continued both at
each hospital site and community locations allowing Governors and members of the Board,
accompanied by clinicians and senior nursing staff, to witness first hand the level of care and
service being provided to our patients. It provides the opportunity to speak with patients and
their visitors directly about the experience they have had during their stay at the Trust. The
panels seek to establish the privacy and dignity afforded to patients, the level of care given
and the standards of the environment around them. The scoring system used during the visits
is constantly being updated to reflect new measuring indicators and criteria to ensure they
remain as meaningful as possible. Reports from the panels are shared with the Council of
Governors to provide assurance.
74
Annual Quality Account 2012-2013
Governors have also been assisting with the recruitment of new members for the Trust, by
visiting a wide range of clinical areas and speaking to our patients about their experiences
of the Trust and feeding back the comments/suggestions received. Some of the Governors
are involved in a number of other groups: the Menu Review Group, Patient Information
Evaluation Group and the Hospital User Group which focus on specific service areas.
The range of reports that are presented to the Council of Governors highlight the
performance and compliance of the Trust against its many performance indicators and
particular areas of focus, which this year have included work around hospital acquired
infections and clostridium difficile. The meetings are conducted in an open, supportive
environment where the opinions and challenges by the Governors are valued and
encouraged. As part of the briefings received regarding new service developments, Governors
receive updates regarding the momentum: pathways to healthcare programme which
aims to transform services and provide care as close to home as possible for our patients.
At a development session in January 2013 the new health and social care priorities were
discussed, following the publication of the Health and Social Care Act 2012, which aims
to provide a seamless pathway of care for patients across health, social care and public
health. The interactive session ensured Governors fully understood what the new healthcare
landscape would look like, the stakeholders involved, new bodies being established, but more
importantly what it would mean for our patients.
The Service Development and Quality Committee, a sub-committee of the Council of
Governors which met on 7 June 2012, 11 October 2012 and 28 February 2013 was
specifically informed regarding initiatives for patients with learning disabilities and dementia,
the outcomes of a cancer peer review, operational efficiencies and readmissions. It also
provided compliance and service performance data in relation to individual performance
indicators, and resilience and emergency preparedness plans.
75
Annual Quality Account 2012-2013
Feedback from NHS County Durham and Darlington Commissioners –
27 February 2013
Many thanks for sending through your Draft Quality Account 2013-14.
As a Commissioner of services for the population of Durham we welcome the opportunity to
make the comments on your Quality Account, the improvements against 2012-13 priorities
and the priorities identified for 2013-14. This plan will support improvements in the quality
and safety of care provided to the population of Durham.
Durham Dales, Easington and Sedgefield CCG acknowledges the improvements seen in
areas of quality identified as priorities for 2012-13. In particular the improvements and
achievements of all key performance for patient safety and quality.
Regarding the work undertaken to reduce the number of patients that die in your care, we
see that this work has impacted positively and although this is not highlighted as a priority
for the coming year, will be mainstream to continue the reduction.
The ground breaking work in relation to Early Warning Signs (EWS) in the community setting
can only be commended and we look forward to seeing further evaluation of this work as it
is rolled out and embedded in practice.
We acknowledge the sterling work the organisation does in relation to end of life care and
being held up as beacon of expertise by colleagues and the satisfaction of patients and carers
is testament to this work.
The challenges with clostridium difficile cannot go unremarked, we recognise the work being
undertaken against reducing the number of cases and as a Commissioner will continue to
support your organisation as well as the wider health community.
We support all the priorities identified for 2013-14 and look forward to seeing the
improvement in the care of patients with Dementia. This programme of work will be
supported by the nationally mandated Commission for Quality and Innovation (CQUIN) for
Dementia included in this year’s scheme.
We support the continued work on reducing the number of avoidable clostridium difficile
cases; improvements in discharge processes to support the quality of patient experience and
improve safety as well as communication to primary care.
Overall we feel you have set out a series of ambitious goals and look forward to working
with you. As Commissioners we feel the Quality Account would benefit from further
elaboration and more detailed reporting on areas for improvement and development as
well as highlighting successes. We will work with you to ensure the recommendations from
the Francis report are implemented and we will ask you to report your progress to us as
Commissioners mid-year to ensure all actions are being implemented.
Yours sincerely
Debbie Edwards
Nurse Advisor/Clinical Quality Lead
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Hartlepool LINk response to Annual Quality Account of North Tees and
Hartlepool NHS Foundation Trust – 5 February 2013
Following receipt of the draft quality account, Hartlepool LINk wish to make a formal
response to the approach taken by the Trust with regards to quality. This response
encompasses the views of Hartlepool LINk members, which have been relayed to both the
Trust via direct correspondence and also encompassed within our published ‘Enter and
View’ statutory reports. Please note this opinion is based on factual ‘Enter and View’ visits
undertaken, referrals received into Hartlepool LINk and actual patient experience of LINk
members.
Our view of future priorities would be of agreement in particular the detail surrounding
Patient Safety, Effectiveness of Care and Patient Experience. We firmly believe that key
recommendations borne out of our collaborative working with the Trust, fit within the
priorities and focus of the quality account.
We have carried out a number of visits to Hartlepool and North Tees Hospital Wards and
Departments and we have been impressed by what was observed and what we have been
told. All visits have been underpinned by what we believe to be openness and honesty with
information freely given, which in turn has allowed Hartlepool LINk to produce meaningful
and robust reports.
At the moment we would welcome the focus on Dementia as this has been a meaningful
piece of work by Hartlepool LINk over the last year and our recommendation for dementia
training across the Trust staff was welcomed and adopted positively. Whilst it is such an
emotive subject regard must also be given to ‘End of Life’ care as it is collectively felt within
Hartlepool LINk that the Trust should be applauded for their progress and work in this area.
One area Hartlepool LINk is keen for the Trust to reconsider is the issue of Transport. Year on
year, as a move towards improving meaningful communication we have formerly requested
the Trust adhere to their obligation in notifying patients of the NHS Healthcare Travel Costs
Scheme. In this current economic climate we feel some patients are choosing to disengage
from treatment purely because they do not have the funds to attend appointments.
Hartlepool Link does welcome the collaborative work with the Local Authority in respect
of transport.
Overall, Hartlepool LINk welcomes the opportunity to respond to the Draft Quality Account
and would hope it will continue to reflect the views we present as the sole statutory
consultation body for the people of Hartlepool in what will be our transition year as
HealthWatch Hartlepool.
Yours Faithfully,
Christopher Akers-Belcher – LINks Co-ordinator
E-mail: c.akersbelcher@hvda.co.uk Website: www.hartlepoollink.co.uk
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Annual Quality Account 2012-2013
Health Scrutiny Forum, Hartlepool – 1 March 2013
Hartlepool Health Scrutiny Forum welcomes the opportunity to contribute to North Tees
and Hartlepool NHS Foundation Trust’s Quality Account for 2013-14. The Forum would like
to thank all members of staff who contribute to improving the experience and outcomes
for patients accessing services provided by North Tees and Hartlepool NHS Foundation
Trust. In relation to communication between the Trust and the Forum, Members feel that
communication and timescales have improved significantly this year, which has contributed to
an improved Quality Account for 2013-14.
Members welcome and support improvements to end of life pathways and are pleased that
end of life care has been identified as a key priority for 2013-14. Members congratulate the
Trust on the development of the new Oasis Suite and would like the suite to be continued, as
it is a facility that will make such a difference to families in difficult times.
Even though medication errors remain small when compared to the number of medicines
dispensed by the Trust, the Forum emphasises the importance of medicine safety. Members
welcome the actions taken by the Trust to reduce medication errors and are supportive of the
positive reporting culture that encourages all staff to report actual medication errors as well
as opportunities for error. To help minimise medication errors which are as a result of illegible
handwriting, Members suggest that a handheld computerised device may be an alternative
to a written prescription to ensure that no errors in medication are made because of illegible
handwriting.
The Forum emphasise the importance of providing nutritional meals to patients and
encourage the Trust to continue to provide patients with a meal of their choice and at a time
that best suits the patient.
The Forum believes that in order to further improve the experiences of patients and visitors,
access to Hartlepool and North Tees Hospitals is an area for consideration and improvement
by the Trust. Members are of the view that experiences of patients and visitors who travel
to the Hospitals are vital and need to be considered to help improve access and patient
experience.
Councillor Stephen Akers-Belcher
Chair of Hartlepool’s Health Scrutiny Forum
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Third Party Statement from Healthcare User Group (HUG)
The main role of the Healthcare User Group (HUG) is to assist the Trust with the Patient and
Public Involvement (PPI) agenda. This is achieved through independent visits to inpatient
wards and outpatient clinics, talking to staff and patients. HUG is also represented on other
Trust committees such as the Quality Standards Steering Group, Patient Environment Action
Team, Audit and Clinical Effectiveness Committee and High Impact Action Groups.
HUG supports the priorities selected for 2013-14 and has had every opportunity to contribute
to the development of these priorities.
In relation to the priorities for 2012-13, our visits have shown the desire of staff to push for
improvements in service quality and outcomes for patients. In particular, staff are very active
in achieving the Dementia strategy and Making the Patient Count with emphasis on dignity,
communication and nutrition. They are very aware of research aiming to meet the needs of
dementia patients, especially through the use of visual aids and bright colours.
We have also observed the desire for improving patient experiences, in particular the further
development of the Carers Diary, contributing to better care and experience for patients and
families.
With regard to infection control, it is disappointing that the target for Clostridium Difficle
has been exceeded. We recognise the efforts the Trust has made to prevent and control the
spread of infection and this has been observed on our visits.
The Trust has presented the correct level of support to allow HUG to perform its independent
visits to various wards and clinics. Any concerns or recommendations have been
acknowledged and implemented promptly.
We view the Quality Accounts as a true and fair reflection of what we have seen on our visits
to North Tees and Hartlepool wards and departments.
HUG will continue to be an impartial and encouraging party, assisting in developing and
monitoring patient services within the Trust.
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NHS Hartlepool and Stockton-on-Tees Clinical Commissioning Group 2 May 2013
NHS Hartlepool and Stockton-on-Tees Clinical Commissioning Group (HAST CCG) commission
healthcare services for the population of Hartlepool and Stockton-on-Tees and welcome
the opportunity to submit a statement on the Annual Quality Account for North Tees and
Hartlepool NHS Foundation Trust.
NHS Hartlepool and Stockton-on-Tees Clinical Commissioning Group (HAST CCG) can confirm
that to the best of its ability, the information provided within the Annual Quality Account is
an accurate and fair reflection of the Trust’s performance for 2012-13.
During 2012-13 we have continued to provide joint robust challenge through our Clinical
Quality Review Groups (CQRGs) to drive improvements in the quality of services and
outcomes for patients. The CQRGs involve key stakeholders who focus on a significant range
of topics including all aspects of safety, clinical effectiveness and patient experience. North
Tees and Hartlepool NHS Foundation Trust have been open and transparent in their approach
to working with commissioners and have responded positively to constructive clinical
challenge. The key areas of particular challenge have included the reduction of clostridium
difficile, MRSA and pressure ulcers, and monitoring of mortality which the Trust has actively
engaged with the Commissioner to improve.
During 2012-13, clinical members of NHS Hartlepool and Stockton-on-Tees CCG have
participated in quality assurance visits, and have continued to attend a number of key
working groups and committees in relation to the patient safety agenda.
As part of their continued desire to be transparent providers, to improve care and
reduce harm, North Tees and Hartlepool NHS Foundation Trust have actively involved the
commissioners in the sharing of lessons learned following serious incidents. The Trust have
also been proactive in promoting and sharing lessons learned with the wider health economy.
The Trust has worked with CCG representatives in agreeing, implementing and delivering a
challenging Commissioning for Quality and Innovation (CQUIN) scheme in 2012-13. This
approach will be maintained in 2013-14 ensuring active clinical engagement.
The CCG have worked with key staff groups during 2012-13 to ensure a seamless transition
in the handover of its commissioner responsibilities working with North Tees and Hartlepool
NHS Foundation Trust in ensuring that the commissioning, provision and monitoring of
safe clinical care for the people of Teesside remains a key priority. The CCG recognises the
hard work and dedication of staff across acute and community settings and the overall
commitment of the Trust to 'Put Patients First' by making patient safety and experience their
number one priority.
NHS Hartlepool and Stockton-on-Tees CCG look forward to continuing to work in partnership
with North Tees and Hartlepool NHS Foundation Trust during 2013-14 to implement the
Francis report and Winterbourne View recommendations and ensure the quality of services
that the Trust provides for the people of Teesside continues to improve.
Chief Officer
Hartlepool and Stockton-on-Tees Clinical Commissioning Group
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Annual Quality Account 2012-2013
Feedback from the Stockton Council’s Adult Service and Health Select
Committee and Stockton LINk
Members of both the Select Committee and LINk welcome the opportunity to comment
on this year’s Quality Account, and provide a joint statement for inclusion in the published
version.
Both the LINk and Committee support the priorities that have been selected for 2012-13.
There have been great improvements in infection control over the previous few years,
and there remains a focus on tackling clostridium difficile (C diff). It is recognised that the
target set for the Trust which it must avoid breaching is a testing one, however, irrespective
of targets, the total number of cases remains higher than for some other Trusts in the
region.
It is noted that there are variations in the numbers of C diff toxin tests undertaken on
samples by different Trusts in the region; a standard approach to the proportion of sample
testing to assist with making comparisons should be considered.
Efforts to tackle the issue locally, particularly the investigation of each occurrence and
to continually review best practice from elsewhere, are welcomed. Given the number
of community-acquired infections, there is also a clear role for community services and
partners to play, in order to spread awareness of the need to reduce C diff infections in the
community.
Discharge should provide a seamless process including the GP, and community services and
care homes were relevant, with communication being key. It is pleasing to note the focus
given to ensuring that discharged patients are returned home ‘Safe and Warm’. This is in
line with the high priority given to the Affordable Warmth agenda by Stockton Council.
Continued focus on dementia is necessary and in line with national and other local
priorities (including the CCG). In order to fully prepare for the increasing numbers of
people with the condition in future years there needs to be an integrated approach across
health and social care settings. In the absence of national guidance, it is pleasing to see
that the Trust is developing and plan to pilot a dementia screening trigger tool for the
community.
The introduction of the Nursing Dashboard is welcome and it is pleasing to note the
positive reception from staff. Public display of key ward-based nursing indicators (such
as falls, pressure sores, compliments, and staff sickness rates) improves transparency,
highlights potential issues, and enables comparisons between wards.
There has been generally very good performance in achieving the quality priorities for
2012-13.
Communication will always be a major priority. From surveys undertaken by non-exec
Board members and Governors, there are high levels of patient feedback in relation to
being treated with dignity and respect. However it was noticeable that 82.6% of patients
responding to the National Inpatient Survey felt that they were given enough privacy; this
does mean that 20% felt that they were not. A key concern of the LINk has always been
privacy and dignity in health and social care settings, and any effort to improve this score
would be welcomed.
Intentional Rounding has been introduced across the Trust and the aim is to provide daily
feedback to staff. The Trust is not yet able to demonstrate that the feedback occurs in
all areas and this should be addressed to ensure that any issues are picked up in a timely
manner.
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Annual Quality Account 2012-2013
End of life care, and particularly communication with patients and carers, continues to be
a high priority for the Committee and LINk, and we have supported the development of
the Family Voice (carer diary) and are pleased to see that it has been identified as good
practice nationally.
Support for vulnerable patients has also been a key issue for the Committee and LINk, and
so we particularly support the work to provide people with a learning disability with some
prior experience of what to expect if admitted to hospital by using an open day event. The
proposed accessible version of the Quality Account for people with a learning disability is
also welcome.
It is understood that Patient Environment Action Team (PEAT) assessments will be replaced
by Patient led Assessments in the Care Environment (PLACE) from April 2013 on a national
basis. PEAT assessments examine cleanliness, facilities, dignity and privacy, and nutrition.
PLACE assessments will formalise the role of patients, family, carers and advocates in the
process, together with continued involvement of Trust personnel. This could be an area to
include in future Quality Accounts.
Following the Francis Report into the Mid-Staffordshire hospital scandal, the Trust was the
first to be inspected by the CQC following the publication of the report. It is pleasing to
note that no recommendations for improvement were identified during the inspection. No
healthcare provider can be complacent and therefore it is good to see that the Trust will
be undertaking a gap-analysis of the report’s recommendations and identify any areas for
further improvement.
Due to the transition to HealthWatch this will be the last joint statement produced by
the Committee in conjunction with the LINk. Members and the LINk have welcomed the
opportunity to work together with the Trust to discuss the Quality Account over the last
few years, and look forward to continued involvement.
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Annex 2
Statement of directors’ Responsibilities in Respect of
the Quality Account
The Directors are required under the Health Act 2009 to prepare a Quality Account for each
financial year. The Department of Health has issued guidance on the form and content of
annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009
and the National Health Service (Quality Reports) Regulations 2010 (as amended by the
National Health Service (Quality Accounts) Amendments Regulations 2011).
In preparing the Quality Account, directors are required to take steps to satisfy themselves
that:
•The Quality Account presents a balanced picture of the trust’s performance over the period
covered;
•The performance information reported in the Quality Account is reliable and accurate;
•There are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to review to
confirm that they are working effectively in practice;
•The data underpinning the measures of performance reported in the Quality Account is
robust and reliable, conforms to specified data quality standards and prescribed definitions,
and is subject to appropriate scrutiny and review; and
•The Quality Account has been prepared in accordance with Department of Health guidance.
The directors confirm to the best of their knowledge and belief they have complied with the
above requirements in preparing the Quality Account.
By order of the Board
Paul Garvin
Chairman
24 May 2013
Alan Foster MBE
Chief Executive
24 May 2013
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Annual Quality Account 2012-2013
Annex 3
Independent Auditors' Limited Assurance Report to the
Council of Governors of North Tees and Hartlepool NHS
Foundation Trust on the Annual Quality Report.
We have been engaged by the Council of Governors of North Tees and Hartlepool NHS
Foundation Trust to perform an independent assurance engagement in respect of North Tees
and Hartlepool NHS Foundation Trust’s Quality Report for the year ended 31 March 2013 (the
‘Quality Report’) and specified performance indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2013 in the Quality Report that have been
subject to limited assurance consist of the following national priority indicators as mandated
by Monitor:
•Number of Clostridium difficile infections; and
•Maximum cancer waiting time of 62 days from urgent GP referral to first treatment for all
cancers.
We refer to these national priority indicators collectively as the “specified indicators”.
Respective responsibilities of the directors and auditors
The directors are responsible for the content and the preparation of the Quality Report in
accordance with the assessment criteria referred to in the Quality Report (the "Criteria"). The
directors are also responsible for the conformity of their Criteria with the assessment criteria
set out in the NHS Foundation Trust Annual Reporting Manual (“FT ARM”) issued by the
Independent Regulator of NHS Foundation Trusts (“Monitor”).
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether
anything has come to our attention that causes us to believe that:
•The Quality Report does not incorporate the matters required to be reported on as specified
in Annex 2 to Chapter 7 of the FT ARM;
•The Quality Report is not consistent in all material respects with the sources specified
below; and
•The specified indicators have not been prepared in all material respects in accordance with
the Criteria.
We read the Quality Report and consider whether it addresses the content requirements of
the FT ARM, and consider the implications for our report if we become aware of any material
omissions.
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Annual Quality Account 2012-2013
We read the other information contained in the Quality Report and consider whether it is
materially inconsistent with the following documents:
•Board minutes for the period April 2012 to the date of signing this limited assurance report
(the period);
•Papers relating to Quality reported to the Board over the period April 2012 to the date of
signing this limited assurance report;
•Feedback from the Commissioners NHS Hartlepool & Stockton-on-Tees Clinical
Commissioning Group dated 2 May 2013;
•Feedback from Governors dated 4 March 2013;
•Feedback from Stockton Council’s Adult Service and Health Select Committee and
Stockton LINk;
•Feedback from Hartlepool LINk dated 5 February 2013;
•The Trust’s 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;
•Care Quality Commission quality and risk profiles dated 31 March 2013; and
•The Head of Internal Audit’s annual opinion over the Trust’s control environment dated
14 May 2013.
We consider the implications for our report if we become aware of any apparent
misstatements or material inconsistencies with those documents (collectively, the
“documents”). Our responsibilities do not extend to any other information.
We are in compliance with the applicable independence and competency requirements of the
Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team
comprised assurance practitioners and relevant subject matter experts.
This report, including the conclusion, has been prepared solely for the Council of Governors
of North Tees and Hartlepool NHS Foundation Trust as a body, to assist the Council of
Governors in reporting North Tees and Hartlepool NHS Foundation Trust’s quality agenda,
performance and activities. We permit the disclosure of this report within the Annual Report
for the year ended 31 March 2013, to enable the Council of Governors to demonstrate
they have discharged their governance responsibilities by commissioning an independent
assurance report in connection with the indicators. To the fullest extent permitted by law, we
do not accept or assume responsibility to anyone other than the Council of Governors as a
body and North Tees and Hartlepool NHS Foundation Trust for our work or this report save
where terms are expressly agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement in accordance with International Standard
on Assurance Engagements 3000 ‘Assurance Engagements other than Audits or Reviews of
Historical Financial Information’ issued by the International Auditing and Assurance Standards
Board (‘ISAE 3000’). Our limited assurance procedures included:
•Evaluating the design and implementation of the key processes and controls for managing
and reporting the indicators;
•Making enquiries of management;
•Limited testing, on a selective basis, of the data used to calculate the specified indicators
back to supporting documentation;
•Comparing the content requirements of the FT ARM to the categories reported in the
Quality Report; and
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•reading the documents.
Annual Quality Account 2012-2013
A limited assurance engagement is less in scope than a reasonable assurance engagement.
The nature, timing and extent of procedures for gathering sufficient appropriate evidence are
deliberately limited relative to a reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial
information, given the characteristics of the subject matter and the methods used for
determining such information.
The absence of a significant body of established practice on which to draw allows for
the selection of different but acceptable measurement techniques which can result in
materially different measurements and can impact comparability. The precision of different
measurement techniques may also vary. Furthermore, the nature and methods used to
determine such information, as well as the measurement criteria and the precision thereof,
may change over time. It is important to read the Quality Report in the context of the
assessment criteria set out in the FT ARM and the directors’ interpretation of the Criteria in
the Quality Report.
The nature, form and content required of Quality Reports are determined by Monitor. This
may result in the omission of information relevant to other users, for example for the purpose
of comparing the results of different NHS Foundation Trusts.
In addition, the scope of our assurance work has not included governance over quality or
non-mandated indicators in the Quality Report, which have been determined locally by North
Tees and Hartlepool NHS Foundation Trust.
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to
believe that for the year ended 31 March 2013;
•The Quality Report does not incorporate the matters required to be reported on as specified
in annex 2 to Chapter 7 of the FT ARM;
•The Quality Report is not consistent in all material respects with the documents specified
above; and
•The specified indicators have not been prepared in all material respects in accordance with
the Criteria.
PricewaterhouseCoopers LLP
Chartered Accountants
Newcastle upon Tyne
24 May 2013
The maintenance and integrity of North Tees and Hartlepool NHS Foundation Trust’s website
is the responsibility of the directors; the work carried out by the assurance providers does not
involve consideration of these matters and, accordingly, the assurance providers accept no
responsibility for any changes that may have occurred to the reported performance indicators
or criteria since they were initially presented on the website.
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Glossary
A&E
Accident and Emergency
ACE Committee
Audit and Clinical Effectiveness Committee - the committee that oversees both clinical
audit (i.e. monitoring compliance with agreed standards of care) and clinical effectiveness
(i.e. ensuring clinical services implement the most up-to-date clinical guidelines).
ACL
Anterior Cruciate Ligament - one of the four major ligaments of the knee
AMT
Abbreviated Mental Test
CABG
Coronary Artery Bypass Graft (or “heart bypass”)
CCG
Clinical Commissioning Group
CHKS
Comparative Health Knowledge System
Clostridium difficile
(infection)
An infection sometimes caused as a result of taking certain antibiotics for other health
conditions. It is easily spread and can be acquired in the community and in hospital.
CLRN
Comprehensive Local Research Network
COPD
Chronic Obstructive Pulmonary Disease
CSP
Co-ordinated System for gaining NHS Permission
CQC
The Care Quality Commission - the independent safety and quality regulator of all health
and social care services in England.
CQRG
Clinical Quality Review Group
CQUIN
Commissioning for Quality and Innovation - a payment framework introduced in 2009 to
make a proportion of providers’ income conditional on demonstrating improvements in
quality and innovation in specified areas of care.
DAHNO
Data for Head and Neck Oncology (Head and Neck Cancer)
DoLS
Deprivation of Liberty Safeguards
Dr Foster
A major provider of healthcare information and benchmarking
DVLA
Driver and Vehicle Licensing Agency
EAU
Emergency Assessment Unit
e-coli (infection)
An infection sometimes caused as a result of poor hygiene or hand-washing
EWS
Early Warning Score - a tool used to assess a patient’s health and warn of any
deterioration
FCE
Finished Consultant Episode - the complete period of time a patient has spent under the
continuous care of one consultant
FOI (act)
The Freedom of Information Act - gives you the right to ask any public body for
information they have on a particular subject
Global trigger tool (GTT)
Used to assess rate and level of potential harm. Use of the GTT is led by a medical
consultant and involves members of the multiprofessional team. The tool enables clinical
teams to identify events through triggers which may have caused, or have potential to
cause varying levels of harm and take action to reduce the risk.
GCP
Good Clinical Practice
GM
General Manager
HCAI
Health Care Acquired Infection
HES
Hospital Episode Statistics
HMB
Heavy Menstrual Bleeding
HQIP
Healthcare Quality Improvement Partnership
HRG
Healthcare Resource Group - a group of clinically similar treatments and care that require
similar levels of healthcare resource.
HSMR
Hospital Standardised Mortality Ratio - an indicator of healthcare quality that measures
whether the death rate in a hospital is higher or lower than you would expect.
HUG
Healthcare User Group
IBD
Inflammatory Bowel Disease
ICNARC
Intensive Care National Audit and Research Centre
LD
Learning Difficulties
IG
Information Governance
Intentional Rounding
A formal review of patient satisfaction used in wards at regular points throughout the day
IPNMB
Integrated Professional Nursing Midwifery Board
IPC
Infection Prevention and Control
Kardex (prescribing kardex)
A standard document used by healthcare professionals for recording details of what has
been prescribed for a patient during their stay.
LD
Learning disabilities
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Annual Quality Account 2012-2013
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LINks
Local Involvement Network - a group established in order to give local people a stronger
voice in how their health and social care services are run.
Liverpool End of Life Care
Pathway
Used at the bedside to drive up sustained quality of care of the dying patient in the last
hours and days of life.
MBRRACE-UK
Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries in the UK
MCA
Mental Capacity Act
MHA
Mental Health Act
MHRA
Medicines and Healthcare products Regulatory Agency
MINAP
The Myocardial Ischaemia National Audit Project
Monitor
The independent regulator of NHS foundation Trusts
MRSA
Methicillin-Resistant Staphylococcus Aureus - a type of bacterial infection that is resistant
to a number of widely used antibiotics.
MUST
Malnutrition Universal Screening Tool
NCEPOD
The National Confidential Enquiry into Patient Outcome and Death
NCRN
National Cancer Research Network
NEPHO
North East Public Health Observatory
NEQOS
North East Quality Observatory System
NICE
The National Institute of Health and Clinical Excellence
NICOR
The National Institute for Cardiovascular Outcomes Research
NIHR
National Institute for Health Research
NNAP
National Neonatal Audit Programme
OFSTED
The Office for Standards in Education
PALS
Patient Advice and Liaison Service
PAS
Patient Administration System
Patient Safety and Quality
Standards (Ps&Qs)
Committee
The committee responsible for ensuring provision of high quality care and identifying
areas of risk requiring corrective action.
PEQS
Patient Experience and Quality Standards
PICANet
Paediatric Intensive Care Audit Network
PROMs
Patient Reported Outcome Measures
Pseudonymisation
A process where patient identifiable information is removed from data held by the Trust
Quality Risk Profile (QRP)
A CQC tool for monitoring compliance with essential standards of quality and safety that
helps to identify where risks lie within an organisation.
R&D
Research and Development
RCA
Root Cause Analysis
RCOG
The Royal College of Obstetricians and Gynaecologists
RCPCH
The Royal College of Paediatric and Child Health
RESPECT
“Responsive, Equipped, Safe and secure, Person centred, Evidence based, Care and
compassion and Timely” - a nursing and midwifery strategy developed with patients
and governors aimed at promoting the importance of involving patients and carers in all
aspects of healthcare.
RMSO
Regional Maternity Survey Office
SBAR
Situation, Background, Assessment and Recommendation - a tool for promoting
consistent and effective communication in relation to patient care.
SCM
Senior Clinical Matron
SHA
Strategic Health Authority
SHMI
Summary Hospital Mortality-level Indicator - a hospital-level indicator which reports
inpatient deaths and deaths within 30-days of discharge at Trust level across the NHS.
SINAP
Stroke Improvement National Audit Programme
SSU
Short Stay Unit
STAMP
Screening Tool for the Assessment of Malnutrition in Paediatrics
STERLING
Environmental Audit Assessment Tool
Tough-books
Piloted in 2010, these mobile computers aim to ensure that community staff have access
to up-to-date clinical information, enabling them to make speedy and appropriate clinical
decisions.
UHH
University Hospital of Hartlepool
UHNT
University Hospital of North Tees
VSGBI
The Vascular Society of Great Britain and Ireland
VTE
Venous Thromboembolism
Annual Quality Account 2012-2013
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North Tees and Hartlepool
NHS Foundation Trust
Annual Quality Account 2012-2013
www.nth.nhs.uk