Annual quality accounts
2012/2013
Annual Quality Account 2012/13
3
Contents
1.0
Part 1: Statement on quality from the chief executive of the Trust
1
2.0
Part 2: Priorities for improvement and statements of assurance from the board
4
Overview of the quality of care against 2012/13 quality priorities
2.1
Priorities for improvement: Overview of the quality of care against 2012/13
quality priorities
4
2.1a
••
4
2.1b
•• Patient safety quality indicators
20
2.1c
•• Patient experience quality indicators
31
2.2
•• Quality priorities for 2013/14
38
2.3
Statements of assurance from the board
40
2.3a
•• Information on the review of services
40
2.3b
•• Information on participation in clinical audits and national confidential
enquiries
40
2.3c
•• Information on participation in clinical research
49
2.3d
•• Information on the Trust’s use of the CQUIN framework
50
2.3e
•• Information on never events
50
2.3f
•• Information relating to the Trust’s registration with the Care Quality
Commission
51
2.3g
•• Information on quality of data
51
2.3h
•• Information on information governance
51
2.3i
•• Information payment by results clinical coding audit
51
2.3j
•• Trust performance against a core set of indicators
51
2.3k
•• Summary Hospital-Level Mortality Indicator (SHMI)
52
2.3l
•• Patient Reported Outcome Measures (PROMS)
54
Clinical effectiveness quality indicators
2.3m
•• Readmissions to hospital
55
2.3n
•• Personal needs of patients
56
2.3o
•• Staff recommending Trust as a provider to friends and family
58
2.3p
•• Risk assessed for venous thromboembolism
59
2.3q
•• Clostridium difficile infection reported within the Trust
60
2.3r
•• Patient safety incidents
61
3.0
Part 3: An overview of the quality of care based on performance in 2012/13
against indicators
64
3.1
•• Performance against 2012/13 indicators
64
3.2
Performance against relevant indicators and performance thresholds
66
3.3
Information on staff survey report
67
3.4
Information on patient survey report
69
1
Annex 1: Statements from commissioners
72
2
Annex 2: Statement from Healthwatch organisations
73
3
Annex 3: Statement from the Overview and Scrutiny Committees
74
4
Annex 4: Statement from the Trust Governors’ service quality monitoring group
76
5
Annex 5: Statement of directors’ responsibilities in respect of the Quality Report
77
6
Annex 6: Independent auditor’s report to the Board of Governors on the
Annual Quality Report
78
7
Annex 7: Glossary
81
8
Annex 8: Mandatory performance indicator definitions
85
ANNEX
5
PART 1:
Statement on quality from the chief executive of
the Northern Lincolnshire and Goole Hospitals NHS
Foundation Trust
I am delighted to be able to take this opportunity to
introduce the annual quality account for the Northern
Lincolnshire and Goole Hospitals NHS Foundation
Trust (also referred to as ‘the Trust’ throughout
this report). Whilst publication of this document is
now mandatory, I feel strongly that this provides
an excellent opportunity for us as an organisation
to outline just some of the focussed pieces of work
undertaken during the last financial year covering
April 2012 to March 2013. I hope from your reading
through this you can understand some of the key
challenges faced by the organisation throughout the
year and also feel assured that the organisation’s staff
at all levels are dedicated to constantly strive to focus
on and improve the quality of care we provide to our
patients, service users and carers.
As a Foundation Trust, the format of our quality
account has to meet certain requirements provided
to us by the Department of Health and Monitor and
as a result in some areas this is quite prescriptive.
Despite this we have done our utmost to provide
the following information in a way that enables all
audiences, but particularly our local population, to be
able to receive and understand the key points.
Whilst we publish this particular account on an
annual basis, I want to assure you that quality and
the indicators chosen to help us focus on and
improve key areas are taken very seriously within
the organisation throughout the year. A monthly
account and performance against key indicators
outlined within this report is provided to the quality
and patient experience committee, chaired by a
non-executive director, who receives and challenges
the report to ensure the organisation is always
striving to improve quality of care and service. This
report is then presented on a monthly basis to myself
and the Trust Board and as a result of this, and our
commitment to transparency, this monthly report is
then available to the public, allowing our Foundation
Trust members within all local communities the
opportunity to be both informed and assured of
our commitment to quality. As a result of these
processes and assurance mechanisms, to the best
of my knowledge the information contained in this
document is accurate.
During the year, the Trust has been under a lot of
scrutiny regarding its performance against various
mortality measures. This has generated a lot of
interest locally. I and the Trust Board therefore
have welcomed the news of the impending visit
from a team lead by Sir Bruce Keogh, NHS Medical
Director, to provide an additional degree of external
scrutiny and support in accelerating our already
comprehensive action plans. We have supported
the planning stages of this review fully, providing
the team with lots of evidence to inform their review
and make it as useful as possible. At the same time
we as a Trust have commissioned external reviews of
our information and clinical systems and assurance
mechanisms from such external organisations as
KPMG auditors, local peer NHS organisations and
experts from other NHS institutions to help guide
the comprehensive internal programme of work that
is underway. As a result of this hard work, I am very
pleased with the continuing improvements in the
Trust’s performance against the various mortality
indicators such as the Risk Adjusted Mortality
Indicator (RAMI) and the most recent iterations of
the Summary Hospital Mortality Indicator (SHMI).
We are confident of ensuring that patient safety
remains a key priority and therefore the positive
results following the implementation in November of
the National Early Warning Score (NEWS) within the
organisation provides me with confidence that any
signs of deterioration in our patients can be identified
and acted on. To ensure that we continue to improve
these are the areas that the Trust have identified as
needing to remain as key quality indicators for the
2013/14 financial year.
You will note that our quality priorities for the coming
financial year which started in April 2013 remain
focussed on improving key areas, some of which
are those areas where progress has been made but
where further work is still necessary. To complement
the Trust Board’s focus on improved quality of patient
care, you will notice that a key quality target also
relates to the morale of the organisations’ workforce
– its dedicated staff from all backgrounds, specialisms
and departments – which ensures that the
organisation is able to provide the services it does.
1
Annual Quality Account 2012/13
The Trust recognises that to provide high quality
services, our staff need to feel engaged, respected,
listened to and appreciated. It is our determination
therefore that this will be a focal point of the Trust’s
work going forward and will feature as high on our
quality improvement plans as clinical improvement
work.
The organisation has performed well during the year
despite a backdrop of immense change within the
National Health Service. I am particularly proud of the
consistently positive feedback we receive from our
patients and service users of their experiences within
our organisation. I am pleased with our continued
improvement with reduction of MRSA within the
organisation and we are focussed on using this good
example of quality improvement to help us improve
our performance with clostridium difficile incidence
throughout this coming year. The Trust actively
promotes the policy of reporting all incidents or near
misses no matter how seemingly insignificant they
may appear to be the staff involved, by doing this we
strive to identify lessons to be learnt which allows
us to then focus on improving patient safety, I am
therefore pleased with the level of Trust reported
incidents as this shows we taking this area very
seriously.
I hope from what I have said and from the following
quality account that you can see that the Trust board
and I are keenly focussed on quality. To support
2
this we have implemented a quality strategy which
further demonstrates this. The overall statement of
intent and vision for this is:
••
‘To provide a range of high quality clinical services
that are financially viable and which allow the
provision of a comprehensive range of emergency
services to our local population’
••
This vision is underpinned by a number of
strategic goals, the first of which states:
••
‘To provide excellent care to patients in a safe and
modern environment’.
The Trust Board and I therefore look forward to
working closely and providing quality leadership
throughout the rest of this coming financial year
to allow our dedicated teams of staff to fulfil the
above strategic goal of providing excellence in a
safe environment. I look forward to outlining our
continuing achievements both throughout the year
in the monthly quality report as well as next year in
our annual quality account publication.
Karen Jackson, Chief executive
About Northern Lincolnshire and Goole Hospitals NHS Foundation Trust
Northern Lincolnshire and Goole Hospitals
NHS Foundation Trust (referred to as ‘The Trust’
throughout this report) consists of three hospitals,
these are:
••
Diana, Princess of Wales Hospital in Grimsby (also
referred to as DPoW)
••
Scunthorpe General Hospital located in
Scunthorpe (also referred to as SGH)
••
Goole and District Hospital (also referred to as
GDH).
The Trust was established as a combined hospital
and community Trust on April 1 2001, and achieved
Foundation Status on May 1 2007. It was formed
by the merger of North East Lincolnshire NHS Trust
and Scunthorpe and Goole Hospitals NHS Trust and
operates all NHS hospitals in Scunthorpe, Grimsby
and Goole. Its name reflects the wider geographical
area in which the Trust is a major provider of health
care.
Running three hospitals, separated by considerable
distances, poses a significant service delivery
challenge, but also allows the Trust to serve a wider
population. NLaG also provides a range of services
delivered outside of hospital settings. Due to these
geographical distances a key way the Trust uses
to help measure and monitor quality of care is
through site by site breakdowns of performance
against various measures. You will see this illustrated
throughout the following sections of the report.
Our core business can be defined as:
••
Delivering a full range of emergency secondary
health care services, including intensive and high
dependency care
••
Maintaining a comprehensive range of planned
services, in an environment of patient choice and
contestability
••
Ensuring a full range of secondary care diagnostic
services are available locally.
The Trust has developed, through extensive
consultation with the local health community, a fiveyear strategic direction. This describes the Trust’s key
strategic priorities for the next five years and beyond,
to support the healthcare requirements of the local
population.
Our primary strategy is “Local Services for Local
People” – to be the provider of choice for the local
health community. This is in line with the strategic
vision of local commissioners:
••
Broadly comprehensive district general hospitals
in Grimsby and Scunthorpe, supported from
Goole
••
Rationalisation, reconfiguration and consolidation
managed in a collaborative way
••
Joint development of modernisation initiatives
across the health community.
For latest news from Northern
Lincolnshire and Goole Hospitals
NHS Foundation Trust visit our
website at: www.nlg.nhs.uk
Follow the Trust on Twitter: @NHSNLaG
3
Annual Quality Account 2012/13
PART 2:
Priorities for improvement and statements of
assurance from the board
2.1 Priorities for improvement: Overview of the quality of care against 2012/13 quality priorities
Information reported within Part 2
Due to the timings necessary to compile the annual quality account, the most recent information available
presented is not always to the end of the financial year. Despite this at least 12 months trending information is
available.
Priorities for improvement
This section of the report highlights the achievement during 2012/13 towards achieving the priorities which we
set out in our Annual Quality Account for 2011/12 for this financial year. The quality priorities are divided into
three sections: clinical effectiveness, patient safety and patient experience.
During 2012/13 the following quality priorities were monitored by the monthly quality report which was
presented and reviewed on a monthly basis by the Trust’s quality and patient experience (QPEC) committee and
the Trust Board.
Section 2.2 of this report (page 38) details the quality priorities for the 2013/14 financial year. In some cases these
quality priorities have changed from those reported on below. Where this is the case, beneath each indicator, the
rationale for the change is explained.
A note on interpretation of the following information
Wherever possible throughout this report, unfamiliar terms or acronyms have been explained in the body of the
report. Where this has not been possible due to compliance with the national template set for the Trust’s annual
quality account submission, every effort has been made to ensure the glossary (page 81) provides the necessary
definition to aid the reader’s interpretation of this information.
2.1a Clinical effectiveness
CE1 – Reduction in mortality ratios
Introduction to data on mortality:
One of the Trust’s most important quality measures is that of mortality. The Trust has invested a lot of work into
this area to ensure that the organisation’s performance with mortality measures is understood, monitored and
acted upon to ensure the quality of care afforded to the Trust’s local population is being consistently improved.
In order to report the Trust’s position on mortality, it is worth explaining some of the different mortality measures
and how the Trust uses these internally.
There are two primary ways to measure mortality, both of which are used by the Trust:
1.
Crude mortality – expressed as a percentage, calculated by dividing the number of deaths within the
organisation by the number of patients treated
2.
Standardised Mortality Ratios (SMR). These are statistically calculated mortality ratios that are heavily
dependent on the quality of recording and coding data. These are calculated by dividing the number of
deaths within the Trust by the expected number of deaths.
4
This expected level of mortality is based on individual, patient specific risk factors that a person will present with
on their admission ie their diagnosis or the reason for their attending the hospital, their age and their existing
medical conditions and illnesses.
These, as well as in hospital data such as the type of admission i.e. an elective admission for a planned procedure
or an unplanned emergency admission with an acute medical/surgical condition, all inform the statistical model’s
calculation of expected mortality within the organisation.
As these Standardised Mortality Ratios (SMRs) are statistical calculations, they are expressed in a specific format.
Based on the average expected mortality within the UK, an organisation’s expected level of mortality would be
expressed at a level of 100.
Therefore an SMRs of more than 100 would be considered to be a higher than would be expected mortality ratio.
Conversely, an SMR of less than 100 would be a mortality ratio less than would be expected.
The Trust’s performance against these indicators is monitored on an ongoing basis by the Trust’s mortality
performance committee (MPC) which is chaired by the Trust’s chairman. This committee oversees the Trust’s
numerous work streams being undertaken to improve the Trust’s actual and reported performance in this area.
One way the committee is empowered to do this is through the monthly mortality report which reports the
Trust’s latest performance with these indicators.
Whilst explaining the different ways in which the Trust monitors performance with mortality measures, it is worth
noting that there are a number of different Standardised Mortality Ratios (SMR) in use throughout the United
Kingdom. The most frequently used SMR indicators are:
1.
Summary-Hospital Level Mortality Indicator (SHMI). The SHMI is the ‘official’ NHS Standardised
Mortality Ratio (SMR). The way it is calculated is the same for all NHS organisations and so allows individual
Trusts to be ranked in terms of their performance.
The Summary-Hospital Level Mortality Indicator (SHMI) however does not just calculate the levels of inhospital expected mortality. The Summary-Hospital Mortality Indicator (SHMI) includes deaths within the
community within 30 days following hospital discharge.
This is the only SMR indicator to include community mortalities, all others focus solely on deaths within
the hospital. As a result of this SHMI is based not only on in-hospital collected data, but also requires data
from the Office for National Statistics.
Due to this methodology, when the SHMI is published each quarter, the time frame being reported on by
the SHMI ranges from 6 months – 18 months behind current performance.
To illustrate this, in April 2013 when the most recent SHMI was published, the reporting period was
October 2011 – September 2012. Whilst the indicator provides a comparable picture of performance, the
Trust has struggled to use the Summary-Hospital Mortality Indicator (SHMI) effectively in order to monitor
Trust performance due to the significant time lag in reporting.
2.
Risk Adjusted Mortality Index (RAMI). The Risk Adjusted Mortality Index (RAMI) is another example of a
Standardised Mortality Ratio (SMR). It is provided to NHS Trusts to use by a private company called CHKS.
The product enables the Trust to use this software to analyse its own internally collected data.
The RAMI is just another example of an information tool for which NHS organisations can use to track and
monitor performance with their mortality ratios. The Risk Adjusted Mortality Indicator (RAMI) whilst an
SMR is calculated differently to the methodology used by the SHMI. This means that direct comparison of
performance against the two indicators is not possible.
One example of a key difference is in connection with patients receiving palliative care. Such patients are
included in the Summary Hospital Level Mortality Indicator (SHMI), however in the RAMI indicator, these
patients would be excluded. The RAMI assess in-hospital mortality only. If a patient were to die following
their discharge from hospital, this would not be reflected in the Trust’s RAMI data.
As a result of this, the RAMI indicator is based on in-hospital collected data only meaning that
performance can be monitored in a much more timely manner usually meaning that data is available four
or five weeks after the event. Alongside SHMI, the Trust has used the Risk Adjusted Mortality Index (RAMI)
heavily in its monitoring and taking action based on mortality ratios. You will see in the following sections
the Trust’s current use of this mortality ratio.
5
Annual Quality Account 2012/13
3.
Hospital Standardised Mortality Ratio (HSMR). This indicator is another example of a Standardised
Mortality Ratio (SMR) provided for NHS organisations to track their performance against mortality indices.
The HSMR is also provided by a commercial company called Dr Foster, who use this indicator to rate NHS
Trust performance on an annual basis in their Good Hospital Guide Publication. In the same way as CHKS
provide their RAMI indicator, NHS Trusts have to pay a subscription to make use of these indicators, and
as the Trust is already using the CHKS product, no subscription is paid for the HSMR indicator and so the
Trust does not have ready access to the results from this indicator.
In exactly the same way as the RAMI calculation methodology differs to that of the SHMI, the HSMR
is calculated using different rules and methodologies for instance HSMR does not include all hospital
mortality, rather it groups deaths within certain chapters and uses these to assess mortality performance.
A note of caution when interpreting Standardised Mortality Ratios:
The use of a Standardised Mortality Ratio (SMR) in assessing and ranking performance must always be interpreted
with caution. As these are ratios of actual deaths against expected levels of mortality they are heavily dependent
on data and the accuracy of recording.
As a result of this, there interpretation is likened to that of a smoke alarm, in the same way as the smoke alarm sounding
does not mean there is definitely a fire, an SMR indicator of above 100 does not definitely indicate a problem.
However,
just as
be unwise
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not investigate,
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(RAMI) Standardised Mortality Ratio (SMR). More information is included on pages 60
These departments
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regarding
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appropriate
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onalso
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mortality.
As a result of the Trust’s continued focus on mortality measures, the first section of the quality report deals with
the Trust’s
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the Risk
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52 regarding
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••
Target: (CE1a) The Trust aspires to achieve a Risk Adjusted Mortality Index (RAMI) below 100. This may take
••
In April 2012 the Trust’s RAMI was 102, in January 2013 the Trust’s RAMI had reduced to 89, a reduction of 13 points.
moreAchievement
(April However,
2012 – during
January
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From
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•• Achievement
(April
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2013):
From May
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RAMI hastrend
been consistently
pace
to
that
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Trust’s
peer
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and
national
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•• The trend line on the chart below illustrates a downward trend reducing at a quicker pace to that of the Trust’s
peerIn
April 2012
the Trust’s
RAMI was 102, in January 2013 the Trust’s RAMI had
comparators
and national
performance
reduced to 89, a reduction of 13 points.
210
Trust (NLAG) Monthly Risk Adjusted Mortality Indicator (RAMI) vs Peer Group
190
170
150
110
90
70
Jan‐10
Feb‐10
Mar‐10
Apr‐10
May‐10
Jun‐10
Jul‐10
Aug‐10
Sep‐10
Oct‐10
Nov‐10
Dec‐10
Jan‐11
Feb‐11
Mar‐11
Apr‐11
May‐11
Jun‐11
Jul‐11
Aug‐11
Sep‐11
Oct‐11
Nov‐11
Dec‐11
Jan‐12
Feb‐12
Mar‐12
Apr‐12
May‐12
Jun‐12
Jul‐12
Aug‐12
Sep‐12
Oct‐12
Nov‐12
Dec‐12
Jan‐13
RAMI 130
NLAG
Peer Average
National Average
Linear (NLAG)
Source:
producedusing
usingCHKS
CHKS
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Source: Information
Information services,
services, produced
Live
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Comment: TheThe
aboveabove
chart illustrates
the Trust’s monthly
RAMI versus
a peer RAMI
group ofversus
comparable
Trustsgroup
and
Comment:
chart illustrates
the Trust’s
monthly
a peer
of
the
national
average.
comparable Trusts and the national average. The RAMI or risk adjusted mortality indicator is
a statistical expression of the Trust’s expected mortality. As referred to in the introduction to
this section, there are other versions of this statistical model, referred to as a Standardised
Mortality
6 Ratio (SMR), RAMI is the main indicator that the Trust uses to monitor this area.
The ‘expected’ aspect of the calculation is heavily dependent on data quality and recording.
The RAMI or risk adjusted mortality indicator is a statistical expression of the Trust’s expected mortality. As
referred to in the introduction to this section, there are other versions of this statistical model, referred to as a
Standardised Mortality Ratio (SMR), RAMI is the main indicator that the Trust uses to monitor this area.
The ‘expected’ aspect of the calculation is heavily dependent on data quality and recording. A RAMI of 100 is the
accepted national average and therefore equates to the Trust’s expected level of mortality.
Anything above 100 demonstrates an above expected mortality rate and anything lower than 100 demonstrates
a lower than expected mortality ratio, according to the statistical model employed.
This chart shows that since August 2012 there has been a reduction of RAMI which brings us far nearer to the
performance of our peers. In January 2013, the monthly RAMI for the Trust was 89. The peer value was 86.
This chart reflects much of the Trust’s focus on these mortality indicators and the action plan currently in place
to ensure the Trust continually improves performance in this area. An example of some of the action already
having been taken is improvements in the accurate recording and coding of appropriate diagnosis groups and
co-morbidities.
Focus on: CHKS
CHKS is a leading provider of healthcare and
healthcare improvement services, developing
solutions for healthcare organisations in over
20 countries.
The Trust uses CHKS Live software to analyse
and report routine Trust performance from
internally collected and coded information
that takes place on a monthly basis. The Trust
is therefore enabled to monitor and act on the
information provided using this software.
RAMI which stands for Risk Adjusted
Mortality Indicator is an example of one key
use of CHKS. By monitoring this mortality
measure and using it to ‘drill down’ key
areas of Trust performance can be identified
and prioritised for improvement work, if
necessary. Alternatively, sometimes this
highlights improvements that could be made
in connection with the Trust’s data collection
or quality of data being used to form the basis
of such data analysis.
Some cases identified from specific project work, were found to have had gaps
in the documented and coded history recorded within the Trust’s information
systems. As already alluded to in the introduction, the Standardised Mortality
Ratios (SMR) base the calculation of expected mortality on such recorded and
coded details.
Therefore by not capturing the full patient ‘story’ the risk factors that are used
to calculate the expected mortality aspect of the calculation will produce a risk
that under reports the expected mortality resulting in a higher than expected
SMR ratio. As a result of this work to improve these systems the RAMI is
noticeably reducing at a faster rate than the peer comparators.
As mentioned in the introduction, a high RAMI score should be taken as an
alert and should be investigated more thoroughly. The mortality performance
committee (MPC) receives the monthly mortality report and based on this
appropriate and clinically lead projects are initiated and overseen.
These projects have taken the form of investigative audits and as a result of this
work and the Trust’s greater understanding of key themes, this approach will
not feature much more action focussed project work. The following indicators
relating to condition specific mortality areas, specifically CE1b deals with
stroke care, CE1c outlines cardiac conditions and CE1d focusses on respiratory
conditions.
These are individual examples of condition specific areas identified as seeming
outliers in terms of the Standardised Mortality Ratio (SMR) where specific
investigative projects have been undertaken and will still feature as part of the
action plan moving forward.
Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality
Account?
Yes, in the 2011/12 quality account, the Trust set out the following as a quality priority for 2012/13:
“The Trust aspires to achieve a RAMI below 100. This may take more than one year to achieve. However
during 2012/13 we aim to achieve a 10 point reduction for the 10 highest RAMIs by site and Health Resource
Group (HRG) chapter, and an overall downward trend.”
Throughout the financial year a lot of work has been invested in monitoring, understanding and acting on
a number of mortality indices. As a result of this and the importance ascribed to this area, the Trust board
requested a monthly report to be commissioned dedicated to this area.
This monthly mortality report compliments the existing monthly quality report and provides the Trust board and
other sub committees with a detailed view of the Trust’s performance against the various mortality indicators.
This level of detail therefore allowed for more in depth reporting and analysis of mortality across the organisation.
7
provides the Trust board and other sub committees with a detailed view of the Trust’s
performance against the various mortality indicators. This level of detail therefore allowed for
more in depth reporting and analysis of mortality across the organisation. As a result of this,
the second element of the 2011/12 quality account indicator set for the 2012/13 financial year
to aim for “a 10 point reduction for the 10 highest RAMIs by site and Health Resource Group
(HRG) chapter, and an overall downward trend” was felt to have been superseded by these
developments. To remain focussed the Trust has prioritised an overall downward trajectory
for the organisation’s mortality indicators as a whole and specific pathway areas relating to
As a result of this, the second element of the 2011/12 quality account indicator set for the 2012/13 financial year to
stroke, cardiac conditions and respiratory, which are outlined following this is sections CE1b,
aim for “a 10 point reduction for the 10 highest RAMIs by site and Health Resource Group (HRG) chapter, and an
CE1c
and CE1d.
overall downward trend” was felt to have been superseded by these developments.
Annual Quality Account 2012/13
To remain focussed the Trust has prioritised an overall downward trajectory for the organisation’s mortality
Rationale
for changing this quality priority for 2013/14: The Risk Adjusted Mortality
indicators as a whole and specific pathway areas relating to stroke, cardiac conditions and respiratory, which are
Indicator (RAMI) is a Standardised Mortality Ratio (SMR). For the indicator to stay relevant
outlined following this is sections CE1b, CE1c and CE1d.
and a useful quality marker an annual rebasing occurs where the average mortality marker of
Rationale
for changing
this quality
The Riskto
Adjusted
Mortality
Indicator (RAMI)
is a
100
is reset.
This annual
eventpriority
makesforit 2013/14:
very difficult
set an
improvement
trajectory
that
Standardised
Ratio (SMR).
the The
indicator
to stay relevant
and a useful
quality indicator
marker an annual
relies
solely Mortality
on a figure
of For
100.
‘official’
NHS wide
mortality
is now the
rebasing occurs
where the
average mortality
marker
of 100 isWhilst
reset. This
annual eventthis
makesofficial
it very difficult
to set is
Summary
Hospital
Mortality
Indicator
(SHMI).
monitoring
indicator
an
improvement
trajectory
that
relies
solely
on
a
figure
of
100.
problematic due to the lack of monthly reporting available from the NHS Information Centre
and
timeNHS
lag
in mortality
the availability
the
recent
data
(as aIndicator
result(SHMI).
of theWhilst
inclusion of
Thethe
‘official’
wide
indicator isof
now
themost
Summary
Hospital
Mortality
community
within 30
days of hospital
Toreporting
address
thesefrom
problems,
monitoring mortality
this official indicator
is problematic
due to thedischarge).
lack of monthly
available
the NHS a new
target
is going
to be
atlag
present
this is inofdiscussion
at data
the (as
Trust’s
Performance
Information
Centre
andused,
the time
in the availability
the most recent
a resultMortality
of the inclusion
of
Committee
community (MPC).
mortality within 30 days of hospital discharge).
To address these problems, a new target is going to be used, at present this is in discussion at the Trust’s Mortality
Target
(CE1b):
To achieve
Performance
Committee
(MPC). a 10 point reduction in the Risk Adjusted Mortality Index (RAMI)
during 2012/13 from stroke and an overall downward trajectory.
Target (CE1b): To achieve a 10 point reduction in the Risk Adjusted Mortality Index (RAMI) during 2012/13 from
stroke and an overall downward trajectory.
••

Achievement (April 2012 – January 2013): During the period of April 2012 and
Achievement
(April 2012
– January
2013):
During
the period
April 2012RAMI
and January
January 2013
an upward
trend
was
noticed,
theofaverage
was2013
116.anInupward
April 2012
trend
noticed,RAMI
the average
was in
116.January
In April 2012
the Trust’s
107, in January
2013athis
thewas
Trust’s
wasRAMI
107,
2013
this RAMI
hadwas
reduced
to 106,
1 had
point
reduced
to
106,
a
1
point
reduction
reduction. Since April 2010, however, the Trust’s performance in this is area has
improved
seen in
following
chart
which
illustrates
a downward
Since
April 2010,as
however,
thethe
Trust’s
performance
in this
is area
has improved
as seen in thetrend
following chart
 which
Theillustrates
previous
12 months,
a downward
trend specifically April 2011 to March 2012, the average RAMI
was 150 versus a RAMI of 116 between April 2012 and January 2013, representing a
•• The previous 12 months, specifically April 2011 to March 2012, the average RAMI was 150 versus a RAMI of 116
34 point reduction in RAMI.
••
between April 2012 and January 2013, representing a 34 point reduction in RAMI.
Trust (NLAG) Monthly Stroke (ICD‐10) Risk Adjusted Mortality Indicator (RAMI) vs Peer Group (Health Resource Group)
400
350
RAMI 300
250
200
150
100
Peer (HRG)
Jan‐13
Dec‐12
Oct‐12
Nov‐12
Sep‐12
Jul‐12
Aug‐12
Jun‐12
Apr‐12
May‐12
Mar‐12
Jan‐12
Feb‐12
Dec‐11
Oct‐11
Nov‐11
Sep‐11
Jul‐11
Aug‐11
Jun‐11
Apr‐11
May‐11
Mar‐11
Jan‐11
NLAG (ICD‐10)
Feb‐11
Dec‐10
Oct‐10
Nov‐10
Sep‐10
Jul‐10
Aug‐10
Jun‐10
Apr‐10
0
May‐10
50
Linear (NLAG (ICD‐10))
Source: Information services, produced using CHKS Live Software
Source: Information services, produced using CHKS Live Software
Directorate
of Clinical
and Quality
April performance
2013
Page 12 area.
of 97 The
Comment:
The above
chart Assurance,
illustrates Trust
in terms of RAMI for this condition specific
Trust performance is based on nationally agreed ICD-10 codes used to represent stroke. No peer comparison is
available to the Trust using the same methodology, so for comparisons sake the peer average stroke HRG (Health
Resource Group) performance is illustrated. The linear trend line demonstrates a downward trend over time since
April 2010.
8
This clinical condition group of stroke has been one of the areas that the Trust has assessed in more detail. As
a result of this project work, the teams within this service based at Diana, Princess of Wales Hospital (DPoW)
and Scunthorpe General Hospital (SGH) have developed a comprehensive action plan to take necessary action
to constantly strive to improve the quality of care provided to patients requiring stroke care. As a result of this
focussed effort, the above chart illustrates the downward trajectory of the Trust’s performance with the Risk
Adjusted Mortality Indicator (RAMI) for this condition specific area since April 2010. Regular meetings are held
with key clinical staff within this service to ensure that any areas requiring additional review are picked up,
incorporated within the action plan and implemented.
Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality
Account?
No, there has been no change to this quality priority during the 2012/13 reporting period.
Rationale for changing this quality priority for 2013/14: A new target is to developed for 2013/14 to take into
account
the difficulties
of setting
improvement
on a numerical
and the delay
in
 Target
(CE1c):
To an
achieve
a 10trajectory
point based
reduction
in the RAMI
Riskfigure
Adjusted
Mortality
obtaining timely SHMI data. This is currently being discussed at the Trust’s Mortality Performance Committee
Indicator (RAMI) during 2012/13 for cardiac conditions and an overall downward
(MPC).
••
trajectory.
Target (CE1c): To achieve a 10 point reduction in the Risk Adjusted Mortality Indicator (RAMI) during 2012/13
cardiac conditions and
an overall
trajectory.
 for Achievement
(April
2012downward
– January
2013): During the period of April 2012 and
••
••
••


January 2013
an upward
noticed
with
average
RAMI
of 2013
84. an
In upward
April 2012
Achievement
(April 2012
– Januarytrend
2013):was
During
the period
of April
2012 and
January
the
Trust’s
RAMI
was
101
in
January
2013
this
had
reduced
to
91,
a
reduction
of 10
trend was noticed with average RAMI of 84. In April 2012 the Trust’s RAMI was 101 in January 2013 this had
points
reduced to 91, a reduction of 10 points
For the period since April 2010, however Trust performance has improved as
For the period since April 2010, however Trust performance has improved as indicated in the following chart
indicated in the following chart which illustrates a downward trend since April 2010
which illustrates a downward trend since April 2010
The previous 12 month period average, specifically April 2011 to March 2012, was
a
The105
previous
12 month
period
specifically
Marchto
2012,
was 1052013,
versus arepresenting
RAMI of 84 in
versus
a RAMI
ofaverage,
84 in the
periodApril
of 2011
Aprilto2012
January
the21
period
of
April
2012
to
January
2013,
representing
a
21
point
reduction
in
RAMI.
point reduction in RAMI.
Trust (NLAG) Monthly Cardiac Conditions (HRG) Risk Adjusted Mortality Indicator (RAMI) vs Peer Group (HRG)
250
RAMI 200
150
100
Peer (HRG)
Jan‐13
Dec‐12
Oct‐12
Nov‐12
Sep‐12
Jul‐12
Aug‐12
Jun‐12
Apr‐12
May‐12
Mar‐12
Jan‐12
Feb‐12
Dec‐11
Oct‐11
Nov‐11
Sep‐11
Jul‐11
Aug‐11
Jun‐11
Apr‐11
May‐11
Mar‐11
Jan‐11
NLAG (HRG)
Feb‐11
Dec‐10
Oct‐10
Nov‐10
Sep‐10
Jul‐10
Aug‐10
Jun‐10
Apr‐10
0
May‐10
50
Linear (NLAG (HRG))
Source: Information services, produced using CHKS Live Software
Source: Information services, produced using CHKS Live Software
Comment:
The
above
illustrates
Trust performance
in terms
RAMIspecific
for thisarea.
condition
Comment: The
above
chartchart
illustrates
Trust performance
in terms of RAMI
for this of
condition
The
specific
area.
The
Trust
performance
and
that
of
the
peer
group
is
based
on
the
cardiac
Trust performance and that of the peer group is based on the cardiac conditions HRG (Health Resource Group),
conditions
HRG
(Health
Resource
Group),
a conditions
pre-defined
grouping
codes
that
a pre-defined
grouping
of hospital
codes that
represent
and surgery
withinof
thehospital
cardiac HRG
chapter.
represent
conditions
and surgery
within
theover
cardiac
HRG
chapter. The linear trend line
The linear trend
line demonstrates
a downward
trend
time since
April 2010.
demonstrates
a downward trend over time since April 2010.
This is another of the key condition specific areas having been identified by the Trust as being an outlier. A project
This
is another
of the
condition
having
identified
thespecific
Trust as
specific
working group
waskey
established
and aspecific
number ofareas
case reviews
werebeen
initiated.
As a resultby
of this
being
A possible
projectand
specific
working
group inwas
established
number of case
actionan
hasoutlier.
been made
due to this,
improvements
service
delivery haveand
beenamade.
reviews were initiated. As a result of this specific action has been made possible and due to
this, improvements in service delivery have been made. This is illustrated in the above chart
9 Risk
which illustrates a downward trajectory in terms of the Trust’s performance with the
Adjusted Mortality Index (RAMI) for this condition specific area. Performance with mortality
Annual Quality Account 2012/13
This is illustrated in the above chart which illustrates a downward trajectory in terms of the Trust’s performance
with the Risk Adjusted Mortality Index (RAMI) for this condition specific area. Performance with mortality
indicators in this group is monitored on a monthly basis with the monthly mortality report.
Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality
Account?
No, there has been no change to this quality priority during the 2012/13 reporting period.
Rationale for changing the quality priority for 2013/14: A new target is to developed for 2013/14 to take into
 Target
(CE1d):
To anachieve
a 10
point based
reduction
in theRAMI
Riskfigure
Adjusted
Mortality
account
the difficulties
of setting
improvement
trajectory
on a numerical
and the delay
in
Indicator
(RAMI)
during
2012/13
for
respiratory
conditions
and
an
overall
downward
obtaining timely Summary Hospital Mortality Indicator (SHMI) data. This is currently being discussed at the Trust’s
trajectory.
Mortality
Performance Committee (MPC).
••
Target (CE1d): To achieve a 10 point reduction in the Risk Adjusted Mortality Indicator (RAMI) during 2012/13
Achievement (April 2012 – January 2013): During the period of April 2012 and
for respiratory conditions and an overall downward trajectory.

January 2013 a downward trend was noticed with an average RAMI of 88. In April
of
Achievement
2012
– January
the period
Aprilhad
2012reduced
and January
2012 the(April
Trust’s
RAMI
was2013):
89, inDuring
January
2013ofthis
to2013
84, aadownward
reduction
trend
waspoints
noticed with an average RAMI of 88. In April 2012 the Trust’s RAMI was 89, in January 2013 this had
five
to 84,entire
a reduction
of five
points
reduced
For the
period
since
April 2010, a downward trend is also observed
••
For The
previous
12 month
period
average,
specifically
the entire
period since
April 2010,
a downward
trend is
also observedApril 2011 to March 2012 was
111 versus RAMI of 88 in this most recent period of April 2012 to January 2013,
•• The previous 12 month period average, specifically April 2011 to March 2012 was 111 versus RAMI of 88 in this
representing a 23 point reduction in RAMI.
most recent period of April 2012 to January 2013, representing a 23 point reduction in RAMI.
••
Trust (NLAG) Monthly Respiratory Conditions (HRG) Risk Adjusted Mortality Indicator (RAMI) vs Peer Group (HRG)
250
RAMI 200
150
100
Peer (HRG)
Jan‐13
Dec‐12
Oct‐12
Nov‐12
Sep‐12
Jul‐12
Aug‐12
Jun‐12
Apr‐12
May‐12
Mar‐12
Jan‐12
Feb‐12
Dec‐11
Oct‐11
Nov‐11
Sep‐11
Jul‐11
Aug‐11
Jun‐11
Apr‐11
May‐11
Mar‐11
Jan‐11
NLAG (HRG)
Feb‐11
Dec‐10
Oct‐10
Nov‐10
Sep‐10
Jul‐10
Aug‐10
Jun‐10
Apr‐10
0
May‐10
50
Linear (NLAG (HRG))
Source:Information
Informationservices,
services, produced
produced using CHKS
Source:
CHKSLive
LiveSoftware
Software
Comment: The above chart illustrates Trust performance in terms of RAMI for this condition specific area. The
Comment:
The above chart illustrates Trust performance in terms of RAMI for this condition
Trust performance and that of the peer group is based on the respiratory conditions HRG (Health Resource
specific
The Trust
performance
and
that
of theconditions
peer group
is basedwithin
on the
Group), aarea.
pre-defined
grouping
of hospital codes
that
represent
and procedures
therespiratory
respiratory
conditions
HRG
(Health
Resource
Group),
a
pre-defined
grouping
of
hospital
codes that
HRG chapter. The linear trend line demonstrates a downward trend over time since April 2010.
represent conditions and procedures within the respiratory HRG chapter. The linear trend
Thisdemonstrates
is another condition
specific area that
theover
Trust has
reviewed
detail.
The Trust’s current mortality action
line
a downward
trend
time
since inApril
2010.
plan contains further plans for this area to receive additional focussed improvement work to ensure that patients
This
is another
specific
area that
thetheTrust
has reviewed
in based
detail.care
The
Trust’s
requiring
admissioncondition
for respiratory
related problems
receive
most appropriate
evidenced
for their
current
mortality
action
plan
contains
further
plans
for
this
area
to
receive
additional
focussed
condition. As a result of the work undertaken so far in this area, the above chart illustrates a downward trajectory
improvement
work
to ensure
that patients
requiringin this
admission
for
respiratory
related
since April 2010, the
additional
plans for clinically
lead improvements
area will help
bolster
this improvement.
problems receive the most appropriate evidenced based care for their condition. As a result
of the work undertaken so far in this area, the above chart illustrates a downward trajectory
since April 2010, the additional plans for clinically lead improvements in this area will help
bolster this improvement.
Has the quality indicator been changed during the year from that set in last years
(2011/12) Quality Account? No, there has been no change to this quality priority during the
10reporting period.
2012/13
Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality Account?
No, there has been no change to this quality priority during the 2012/13 reporting period.
Rationale for changing quality priority for 2013/14: A new target for mortality is needed as a result of the work
undertaken in this area, the details of this indicator are still being agreed with the Trust’s mortality performance
CE2
– ‘Check
committee
(MPC)Your
at the Charts’
point of writing this report.
Target – To fully implement the ‘Check Your Charts’ element of the Patient Safety First
Campaign
CE2 – ‘Check Your Charts’
Achievement
2012
– March
2013):
SinceofOctober
2012,
routine monitoring
Target – To fully(October
implement the
‘Check
Your Charts’
element
the Patient
Safetywhen
First Campaign
of this indicator, in line with National Institute for Health and Care Excellence (NICE)
Achievement (October 2012 – March 2013): Since October 2012, when routine monitoring of this indicator, in line
Technology
Appraisal Guidelines (TAG) 50 began, 99% of observations, assessed using a
with National Institute for Health and Care Excellence (NICE) Technology Appraisal Guidelines (TAG) 50 began, 99% of
random
sample
audit
been compliant
these
laid
observations, assessed
usingmethodology
a random sample have
audit methodology
have beenwith
compliant
withrecommendations
these recommendations
out
by
NICE.
laid out by NICE.
320
99.7
Patient sample (n=)
310
280
100
98.9
311
300
290
100
97.1
297
290
283
281
270
95.6
267
260
250
240
Oct
Nov
Dec
Patient sample audited
Source: Information services, Nursing Dashboard v4.0
Source: Information services, Nursing Dashboard v4.0
Jan
Feb
100
99
98
97
96
95
94
93
92
91
90
Percentage compliance (%)
Trust % complaince with the check your charts element and sample details
Mar
% compliance with NICE TAG 50
Comment: The above chart illustrates the Trust percentage compliance with the check your
Comment: The above chart illustrates the Trust percentage compliance with the check your charts element. On
charts element. On the primary vertical axis the number of patients sampled each month to
the primary vertical axis the number of patients sampled each month to ascertain compliance is shown and on
ascertain
compliance is shown and on the secondary vertical axis, the percentage
the secondary vertical axis, the percentage compliance in each month with this indicator based on NICE TAG 50
compliance
guidelines. in each month with this indicator based on NICE TAG 50 guidelines.
As already referred to in the preceding sections
As already referred to in the preceding sections dealing with specific mortality
dealing with specific mortality quality indicators,
quality indicators, focussed mortality improvement plans are in place as are
Focus on: Nursing
Dashboard
focussed
mortality improvement plans are in place
condition specific working groups, all of which are overseen by the Trust’s Mortality
as are condition specificPerformance
working groups,
all of which
Focus
on:quality
Nursing
Dashboardwork
The nursing dashboard is a tool that
Committee (MPC). At the same time,
other
improvement
are
overseen
by
the
Trust’s
Mortality
Performance
provides a mechanism for feedback
streams have been underway within nursing. The
Onenursing
of thesedashboard
projects and
listed
is a
tool as
that
Committee
(MPC). At athe
same
time,forother
on performance based
on important
provides
mechanism
for feedback
quality
indicator
2012/13quality
related to this check
youra charts
indicator.
This was on
measures of nursing.
improvement work streams
have
based on important
a National
Patientbeen
Safety underway
Agency (NPSA) auditperformance
tool to help organisations
monitor
measures of
nursing.
within
nursing.
One
of
these
projects
and
listed
as
a
and
improve
the
frequency
of
key
nursing
observations
to
improve
detection
of the
It is designed to improve nursing care
quality
for 2012/13
related
toand
this
check
deteriorating
patient
ensure
appropriate Itaction
was
taken
in
such
cases.
Prior
to
quality by providing
frontlineindicator
staff
is designed to improve nursing care
charts
indicator. This
was2012,
a National
Patient
quality
byscore
providing
staffAt
with
with information onyour
trends,
emerging
November
the Trust used
a deteriorating
patient
calledfrontline
the Patient
Risk
information
on trends,
emerging
problems and successes.
Safety Agency (NPSA)
audit
tool for
tothe help
(PAR) score,
this allowed
results of specific
observations
to yield
a score and
problems and successes.
organisations
monitor
and
improve
the
frequency
of
based
on
the
score
defined
actions
necessary
to
guide
nursing
staff
in
their
care of
Such metrics and indicators can
Such
metrics
and
indicators
can
key
nursing
observations
to
improve
detection
of
the
such
deteriorating
patients.
In
November
2012,
the
PAR
score
was
replaced
with
the
empower the public to choose between
empower
the
public
to
choose
between
National
Early
Warning
Score
(NEWS).
This
nationally
developed
deteriorating
patient
deteriorating
patient
and
ensure
appropriate
action
care options which matter to them as
options
which and
matter
to them
as
much as it matters to
the taken
nursingin
andsuch cases.
scorePrior
provided
better warning
system with care
its own
predefined
clearly
marked
was
to aNovember
2012,
much as it matters to the nursing and
midwifery profession.
documentation
to support
identify and act
quicker.
the Trust used a deteriorating
patient
scorestaff
called
midwifery profession.
the Patient At Risk (PAR) score, this allowed for the
results of specific observations to yield a score and
based on the score defined actions necessary to
11
guide nursing staff in their care of such deteriorating
patients. In November 2012, the PAR score was replaced with the National Early Warning
Annual Quality Account 2012/13
The above chart highlights some months were performance dipped noticeably in the months following the
adoption of this new deteriorating patient score. As a result of this monthly monitoring in the quality report,
this was highlighted and additional education, retraining and focus was placed on the National Early Warning
Score (NEWS) by members of the Chief Nurse Directorate. As observed in more recent months, performance has
returned to 100 per cent compliance.
Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality Account?
No, there has been no change to this quality priority during the 2012/13 reporting period.
Rationale for changing the quality priority for 2013/14: The Trust recognises the importance of timely patient
observations and as a result of this, on the November 26 2012 the National Early Warning Scoring (NEWS) system
was adopted by the Trust.
NEWS scoring allows patient deterioration to be clearly observed and appropriate action to be taken. NEWS
replaced the Trust’s previous deteriorating patient identifier the Patient at Risk (PARs) scoring system.
During March and April 2013 the Trust’s compliance with NEWS scoring will be audited. The on-going monitoring
of NEWS compliance within the Trust has also been added to the Trust’s Quality Priorities for 2013/14 (see page 38
of this report).
News release:
Training to help tackle mortality rates
Training designed to help clinical staff spot deteriorating patients is being made mandatory at Northern
Lincolnshire and Goole Hospitals NHS Foundation Trust (NLAG).
The ALERT course, which stands for ‘acute and life threatening events: recognition and treatment’ was
developed by staff at Portsmouth Hospitals NHS Trust. It teaches doctors and nurses to anticipate,
recognise and prevent patients from becoming critically ill.
The one day course, which is both theoretical and practical, includes patient scenarios covering many
different conditions that staff may come across. Although the course is offered at other Trusts, NLAG is one
of the first in the country to make it mandatory for all clinical staff.
Those working in acute areas will be prioritised as the training is rolled out and staff will be required to
complete the course once every four years.
Feedback from those who have taken the course previously has been very positive, with comments
including: “Brilliant day – can’t fault it. Fantastic learning, course should become mandatory training”, “It is
one of the best courses I have ever been on” and “Excellent course – good for improving knowledge and
recognising and treating ill patients – should be mandatory!”.
A similar half day course for healthcare assistants (HCA) is also being introduced as mandatory. Created by
the same people, the BEACH (bedside emergency care for health care workers) course was developed to
train HCAs in basic techniques and give them the skills needed to recognise deteriorating patients.
Once staff have completed the training they are added to a national database, so if they move jobs they
have evidence they have completed the course.
Karen Dunderdale, chief nurse at the Trust, said: “It is vital that all of our clinical staff know what signs
to look out for so that we can intervene as early as possible with these patients and prevent them from
becoming critically ill.”
Liz Scott, medical director at the Trust, said: “We are working very hard to do everything we can to
improve our mortality position at the Trust and making this course mandatory is just one small part of this
significant work.”
12
CE3 – Patient Observations
Target: For patient observations to have been recorded at in accordance with planned
frequency in 95% of cases.
Achievement
2012 Observations
– February 2013): Since April 2012, the Trust achieved this target
CE3(April
– Patient
in 97% of patient
observations
assessed. In months were performance fell below the 95%
Target: For patient observations to have been recorded at in accordance with planned frequency in 95% of cases.
threshold, Quality Matrons have been involved in these areas with a view to identifying and
Achievement (April 2012 – February 2013): Since April 2012, the Trust achieved this target in 97% of patient
targeting any
problem areas.
observations assessed. In months were performance fell below the 95% threshold, Quality Matrons have been
involved in these areas with a view to identifying and targeting any problem areas.
Feb‐13
Jan‐13
Dec‐12
Nov‐12
Oct‐12
Sep‐12
Aug‐12
Jul‐12
Jun‐12
May‐12
Apr‐12
Mar‐12
Feb‐12
Jan‐12
Dec‐11
Nov‐11
Oct‐11
Sep‐11
Aug‐11
Jul‐11
Jun‐11
May‐11
105%
100%
95%
90%
85%
80%
75%
70%
65%
60%
Apr‐11
Percentage (%) Patient observations recorded in accordance with planned frequency DPoW
Apr‐ May‐ Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐ Mar‐ Apr‐ May‐ Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐
11 11 11 11 11 11 11 11 11 12 12 12 12 12 12 12 12 12 12 12 12 13 13
100%100%100%100%100% 99% 99% 100% 99% 100% 99% 100% 92% 97% 100%100%100%100% 94% 100% 99% 95% 95%
SGH
100%100%100%100%100%100%100%100% 83% 92% 99% 98% 98% 98% 90% 100% 99% 100%100%100% 99% 99% 93%
GDH
97% 94% 83% 73% 88% 80% 90% 100% 85% 100%
100%100% 77% 76% 100%100%100%100%100%100%100%100%
Threshold 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%
Source: Information services, Nursing Dashboard v4.0
Source: Information services, Nursing Dashboard v4.0
KEY to abbreviations:
DPoW: Diana, Princess of Wales Hospital, Grimsby
KEY to abbreviations:
DPoW: Diana, Princess of Wales Hospital, Grimsby
SGH: Scunthorpe General Hospital,
GDH: Goole and District Hospital
Comment: The above chart illustrates the percentage of patient
SGH: Scunthorpe General Hospital,
observations recorded within the planned frequency or twice daily. The
GDH: Goole and District Hospital
vertical axis demonstrates the percentage compliance with this indicator
whilst the horizontal axis outlines the months in which this indicator has
Comment:been
The
abovegoing
chart
measured,
backillustrates
to April 2011. the percentage of patient
observations recorded
within the planned frequency or twice daily. The vertical axis demonstrates the percentage
As referred to at the beginning of this report, the Trust is made of up of three hospital sites and for some
complianceindicators,
with this
indicator whilst the horizontal axis outlines the months in which this
the ability to benchmark individual site performance is extremely valuable especially in view of the
indicator has
been
measured,
goingtheback
geographical distances between
sites. to April 2011.
this particular example, the chart demonstrates the Trust’s monitoring of another key nursing measure of
As referredInto
at the beginning of this report, the Trust is made of up of three hospital sites
quality that has a large impact on mortality.
and for some indicators, the ability to benchmark individual site performance is extremely
Linked to theinprevious
indicator
(CE2) this quality priority
relates to
the recording
key patient
observations
valuable especially
view of
the geographical
distances
between
theofsites.
In this
particular
that are the foundation for the deteriorating patient scores which are so useful in identifying and acting when a
example, the chart demonstrates the Trust’s monitoring of another key nursing measure of
patient is highlighted as having deteriorated.
quality that has a large impact on mortality. Linked to the previous indicator (CE2) this quality
It is worth
noting
that the above
to November
2012 reflectsthat
performance
withfoundation
the observations
priority relates
to the
recording
ofchart
keyprior
patient
observations
are the
for the
recorded in line with the Patient At Risk (PAR) score and after November 2012, the indicator mirrors the
deteriorating patient scores which are so useful in identifying and acting when a patient is
observations taken that inform the newly implemented National Early Warning Scoring system (NEWS).
highlighted as having deteriorated. It is worth noting that the above chart prior to November
Has the
quality indicator
been
changed
during the year
from thatinsetline
in last
year’s
(2011/12)
Quality
2012 reflects
performance
with
the
observations
recorded
with
the
Patient
At Risk
Account?
(PAR) score and after November 2012, the indicator mirrors the observations taken that
Yes, the wording
for this indicator
has been
changed
from that
documented
in the(NEWS).
Trust’s 2011/12 quality account,
inform the newly
implemented
National
Early
Warning
Scoring
system
which read:
“To ensure patient observations have been recorded at least twice daily.”
Directorate of Clinical and Quality Assurance, April 2013
Page 18 of 97
13
Annual Quality Account 2012/13
As illustrated by the target statement at the start of section CE3, the wording has changed slightly, however
the substance of the indicator itself is unchanged and demonstrates the Trust’s performance with patient
observations being recorded in line with planned frequencies or in other words, twice daily.
Rationale for changing the quality priority for 2013/14: During November 2012 the National Early Warning
Scoring (NEWS) system was adopted by the Trust. NEWS scoring allows patient deterioration to be clearly
observed and appropriate action to be taken.
NEWS replaced the Trust’s previous deteriorating patient identifier the Patient at Risk (PARs) scoring system. Due
to the high priority of this early warning scoring system, a specific quality priority will be dedicated to compliance
with this indicator (see the Trust’s quality priorities for 2013/14 page 38 of this report).
News release:
New-look bedside documents to improve safety
A new type of bedside documentation, called the National Early Warning Score or NEWS, has
been introduced at hospitals in Grimsby, Scunthorpe and Goole, to help improve patient safety.
Chief nurse Karen Dunderdale said: “The NEWS scheme was launched last year and we decided
to implement it as early as possible because it can have a crucial impact on patient safety.
“NEWS is a coherent document that provides a more consistent way of monitoring patients than
the Patient At Risk Score method we used previously. The introduction of the system has gone
very smoothly and effectively.
“The success of the launch across all our wards at Scunthorpe, Grimsby and Goole hospitals is
down to our dedicated doctors and nurses, who have adapted to the new system very quickly.
“The staff have really taken to it and I’m very proud of them.”
Every hospital bed has a chart that is used to record measurements such as the patient’s pulse
rate, blood pressure and temperature. These measurements help the nursing and medical teams
decide the severity of illness of the patient and if the patient needs more urgent care.
“It has been so successful we are now looking at using the scheme in the community.”
14
CE4 – National Early Warning Score (NEWS)
Target: A Completed NEWS Score to have been recorded with each set of observations in
95% of cases.
CE4 – National Early Warning Score (NEWS)
Target: A Completed NEWS Score to have been recorded with each set of observations in 95% of cases.
Achievement
(April 2012
– February
2013):
Theachieved
Trustthis
achieved
in 93% of
Achievement
(April 2012
– February 2013):
The Trust
indicator in this
93% ofindicator
patient observations
audited. As mentioned
in this report, NEWS
is listed
a quality
priority
for 2013/14
and so will
patient observations
audited.already
As mentioned
already
in asthis
report,
NEWS
is listed
asbea quality
monitored and
on a monthly
the qualityon
report
and a final position
againthe
be reported
2013/14
priority for 2013/14
so willbasis
bewithin
monitored
a monthly
basis will
within
qualityin the
report
and
quality
account.
a final position will again be reported in the 2013/14 quality account.
DPoW
Feb‐13
Jan‐13
Dec‐12
Nov‐12
Oct‐12
Sep‐12
Aug‐12
Jul‐12
Jun‐12
May‐12
Apr‐12
Mar‐12
Feb‐12
Jan‐12
Dec‐11
Nov‐11
Oct‐11
Sep‐11
Aug‐11
Jul‐11
Jun‐11
May‐11
105%
100%
95%
90%
85%
80%
75%
70%
65%
60%
Apr‐11
Percentage (%) A completed National Early Warning Score (NEWS) has been recorded with each set of observations
Apr‐ May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐ Mar Apr‐ May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐
11 ‐11 11 11 11 11 11 11 11 12 12 ‐12 12 ‐12 12 12 12 12 12 12 12 13 13
82% 84% 85% 98% 93% 90% 87% 93% 99%100%95% 99% 98% 98% 93% 84% 96% 92% 94% 99% 99% 99% 94%
SGH
76% 79% 99% 89% 95% 98%100%96%100%96%100%99%100%85% 82% 99% 89% 92% 94% 91% 97% 87% 93%
GDH
100%97% 73% 90% 67% 68% 86% 80% 67% 96%
100%100%87% 84% 83%100%90% 86% 90%100%90%100%
Threshold 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%
Source: Information services, Nursing Dashboard v4.0
Source: Information services, Nursing Dashboard v4.0
Comment: The above chart illustrates the percentage of observations
KEY to abbreviations:
DPoW:
Diana,National
Princess
ofWarning
Wales Hospital,
Grimsby
which contained
a completed
Early
Score (NEWS).
The
SGH:
Scunthorpe
General
Hospital,
vertical axis illustrates the percentage compliance with this indicator and
GDH: Goole and District Hospital
the horizontal axis outlines the months in which this indicator has been
KEY to abbreviations:
DPoW: Diana, Princess of Wales Hospital, Grimsby
SGH: Scunthorpe General Hospital,
GDH: Goole and District Hospital
measured, going back to April 2011.
Comment: The above chart illustrates the percentage of observations which contained a
The chart also demonstrates a hospital site break down of the data. In line with the comments made in indicator
completed National
Early Warning Score (NEWS). The vertical axis illustrates the percentage
CE2 and CE3, this indicator and the questions used to capture this information were changed slightly in November
compliance towith
this
indicator
andfrom
thePatient
horizontal
axis
outlines
the
in which
reflect the Trust’s
moving away
At Risk (PAR)
scoring
to National
Earlymonths
Warning Scoring
(NEWS). this
indicator has been measured, going back to April 2011. The chart also demonstrates a
This again outlines the proactive steps being taken by nursing staff throughout the organisation to improve the
hospital siteidentification
break down
of the data. In line with the comments made in indicator CE2 and
and action taken for those patients identified as having deteriorated.
CE3, this indicator and the questions used to capture this information were changed slightly
in November to reflect the Trust’s moving away from Patient At Risk (PAR) scoring to
National Early Warning Scoring (NEWS). This again outlines the proactive steps being taken
by nursing staff throughout the organisation to improve the identification and action taken for
those patients identified as having deteriorated.
15
Annual Quality Account 2012/13
Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality
Account?
Yes, in the 2011/12 quality account, the Trust set the following quality priority:
“A Completed PARS Score to have been recorded with each set of observations in 95 per cent of cases.”
The Trust amended this quality indicator during 2012/13 as a result of the Trust’s adoption of the National Early
Warning Score (NEWS) in November 2012.
The NEWS scoring system aims to recognise patients that are at risk of deteriorating in order to proactively
change treatment as necessary. Therefore previous data from April 2011 – October 2012 is reporting performance
with Patient at Risk Scores (PARs), the previous deteriorating patient trigger used by the Trust. Post-November
2012, performance with regard to NEWS was monitored.
Rationale for changing the quality priority for 2013/14: A very similar indicator will be used in the monitoring
of quality performance in 2013/14.
This will be a more specific assessment of compliance with NEWS both in terms of documented observations and
appropriate action taken as a result.
News release:
Having one National Early Warning Score (NEWS) with
the same charts in every hospital will:
••
Provide the basis for a unified and systematic approach to both the first assessment of the patient and
continuous tracking of their clinical condition throughout their stay, with a simple trigger for escalating
their care
••
Standardise the training of all staff engaged in the care of patients in hospitals in the National Early
Warning Score system, so that staff should only need to be trained once instead of each time they move
to a hospital that has a different system
••
Provide standardised data on regional variations in illness severity and resource requirements, as well as
objective measurements of illness severity and clinical outcomes – an invaluable research resource.
16
CE5 – Emergency Re-admissions (Dementia)
Target: To realise a downward trajectory for emergency re-admission rates for
patients with dementia.
CE5 – Emergency Re-admissions (Dementia)
Target:
To realise
a downward
trajectory2012):
for emergency
re-admission
rates
for patients withadementia.
Achievement
(April
2012
– December
The chart
below
demonstrates
downward
trajectory for
emergency
re-admission
rates
for
patients
admitted
to
the
Trust
with
dementia.
Achievement (April 2012 – December 2012): The chart below demonstrates a downward trajectory for
25.00%
Emergency readmission rates for dementia patients discharged 20.00%
15.00%
10.00%
5.00%
Trust
Dec‐12
Nov‐12
Oct‐12
Sep‐12
Aug‐12
Jul‐12
Jun‐12
May‐12
Apr‐12
Mar‐12
Feb‐12
Jan‐12
Dec‐11
Nov‐11
Oct‐11
Sep‐11
Aug‐11
Jul‐11
Jun‐11
May‐11
0.00%
Apr‐11
Emergency Re‐admission Rates (%)
emergency re-admission rates for patients admitted to the Trust with dementia.
Linear (Trust)
Source: Information services team, coded data
Source: Information
services team, coded data
Comment: The above chart illustrates the percentage of patients with dementia who were readmitted to the
Trust as an emergency following their hospital discharge. The vertical axis demonstrates the percentage of such
on the
horizontal
line the months
where data is available
to outline
Trustdementia
performancewho
againstwere
Comment:patients
The whilst
above
chart
illustrates
the percentage
of patients
with
this
indicator
are
shown.
The
bold
line
represents
the
Trust
performance
since
April
2011
and
the
linear
trend line
readmitted to the Trust as an emergency following their hospital discharge. The vertical
axis
clearly illustrates a downward trajectory for this indicator.
demonstrates the percentage of such patients whilst on the horizontal line the months where
Has the quality
indicator
beenperformance
changed during against
the year from
set in lastare
year’s
(2011/12)The
Quality
data is available
to outline
Trust
thisthat
indicator
shown.
bold line
Account?
represents the Trust performance since April 2011 and the linear trend line clearly illustrates
a downward
for
indicator.
No, trajectory
there has been
nothis
change
to this quality priority during the 2012/13 reporting period.
Rationale indicator
for changing the
quality
priority forduring
2013/14: Due
the limited
nature
of benchmarking
datayears
with
Has the quality
been
changed
thetoyear
from
that
set in last
which
to
compare
the
Trust
performance
with
peers,
the
value
of
this
indicator
was
limited.
(2011/12) Quality Account? No, there has been no change to this quality priority during the
2012/13 reporting
period.
Also in response
to the national priority of dementia and the national Commissioning for Quality and Innovation
(CQUIN) indicator, it was felt that inclusion of monthly performance with this CQUIN indicator regarding dementia
a more usefulthe
indicator
going forward.
Rationale would
for be
changing
quality
priority for 2013/14: Due to the limited nature of
benchmarking
data
with which
to comparefor
the
Trust
with please
peers,
value on
of this
For a full
explanation
of the Commissioning
Quality
andperformance
Innovation framework,
seethe
the glossary
indicator was
Also
in response
to the
national
priority
dementia
and the national
pageslimited.
81. For more
information
on the CQUIN
scheme
see section
2.3d on of
page
50.
Commissioning for Quality and Innovation (CQUIN) indicator, it was felt that inclusion of
monthly performance with this CQUIN indicator regarding dementia would be a more useful
indicator going forward. For a full explanation of the Commissioning for Quality and
Innovation framework, please see the glossary on pages 89. For more information on the
CQUIN scheme see section 2.3d on page 57.
Directorate of Clinical and Quality Assurance, April 2013
17
Page 22 of 97
Annual Quality Account 2012/13
News release:
Improvements in care for dementia patients
Improvements are being made to the care that patients with dementia receive at the Northern
Lincolnshire and Goole Hospitals NHS Foundation Trust.
A new initiative called ‘my life’, which aims to ensure people with dementia get patient centredcare, is being introduced, awareness training is being rolled out to all clinical staff, a new
screening tool has been introduced, dementia champions are being allocated to wards and
physical improvements have been made to ward areas.
Tara Filby, deputy chief nurse at the Trust, said: “It is so important that we constantly strive to
improve the care we provide to patients with dementia. We know that in the future hospitals will
see many more older patients admitted and we want to make sure we are at the forefront of the
very best care for our older population.”
This week, May 19 to May 25, is dementia awareness week - the Alzheimer’s Society’s annual
flagship campaign. ‘Worrying changes nothing - talking changes everything’ is the focus of the
campaign for this year.
Stroke Unit at Grimsby hospital enhanced
Being admitted to a hospital ward can be disorientating and frightening for someone with
dementia and it may make them more confused and anxious than usual. They sometimes find
the environment loud and unfamiliar, and they might not understand why they are there.
In an attempt to ease this, staff on the stroke unit at Grimsby’s Diana, Princess of Wales Hospital
have looked at how they can help make the ward environment less confusing for dementia
patients.
Thanks to a generous donation from the Grimsby Hospital League of Friends they’ve been able
to make simple changes that will provide enhanced care for patients with dementia.
18
CE6 – Length of stay (dementia)
Target: To realise a downward trajectory for the length of stay for patients with
dementia during 2012/13.
CE6 – Length of stay (dementia)
Achievement (April 2012 – December 2012): The following chart highlights the length of
To realise a downward trajectory for the length of stay for patients with dementia during 2012/13.
stayTarget:
for patients
with dementia and demonstrates that performance throughout the year has
Achievement
(April
– December
2012): The following
chart highlights
length of
stay
for patients from
broadly
remained
the2012
same.
No downward,
or conversely
upwardthetrends
are
discernible
with dementia and demonstrates that performance throughout the year has broadly remained the same. No
the data.
downward, or conversely upward trends are discernible from the data.
Dec‐12
Nov‐12
Oct‐12
Sep‐12
Aug‐12
Jul‐12
Jun‐12
May‐12
Apr‐12
Mar‐12
Feb‐12
Jan‐12
Dec‐11
Nov‐11
Oct‐11
Sep‐11
Aug‐11
Jul‐11
Jun‐11
May‐11
20
18
16
14
12
10
8
6
4
2
0
Apr‐11
Length of stay (LOS) ‐ days Average length of stay (LOS) for patients with dementia Apr‐ May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐ Mar Apr‐ May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐
11 ‐11 11 11 11 11 11 11 11 12 12 ‐12 12 ‐12 12 12 12 12 12 12 12
DPoW 12.4 7.7 9.5 7.7 8.2 8.8 9.1 9.2 9.5 10.3 8.5 8.2 9.1 9.0 10.3 9.8 11.1 9.4 8 9.5 11.8
SGH
9.4 5.6 7.1 8.4 7.4 7.1 5.9 8.1 7.4 7.5 6.9 5.2 6.4 9.8 8.8 8.4 8.6 8.1 9.1 8.7 11.2
GDH 10.2 10.4 6.3 10.8 4.2 13.6 10.1 7.9 12.1 10.3 8.4 9.3 5.8 6.2 5.7 6.0 17.5 10.6 0
0
10
KEY to abbreviations:
DPoW: Diana, Princess of Wales The above DPoW:
chart demonstrates
the average
length
of stay
for
Hospital, Grimsby
KEY Comments:
to abbreviations:
Diana, Princess
of Wales
Hospital,
Grimsby
Scunthorpe
General Hospital,
patients with dementia.SGH:
The vertical
axis demonstrates
the average length SGH: Scunthorpe General Hospital,
GDH:
and
Districtwith
Hospital
GDH: Goole and District Hospital
of hospital stay (LOS) in days
forGoole
patients
admitted
dementia whilst the
Source:
Information
services
team,
coded
data
Source:
Information
services
team,
coded
data
horizontal axis illustrates the months where this has been measured, starting
Comments:
The above chart demonstrates the average length of stay for patients with
in April 2011. A breakdown of performance at site level is also helpful for more detailed internal monitoring of this area.
dementia. The vertical axis demonstrates the average length of hospital stay (LOS) in days
The Trust-wide
dementia
delivery
plan that
was generated
following
the results
of the the
national
dementia
audit,this
for patients
admitted
with
dementia
whilst
the horizontal
axis
illustrates
months
where
included
a
number
of
actions
to
assist
with
the
improvement
in
Length
of
Stay
(LOS)
for
patients
with
dementia.
has been measured, starting in April 2011. A breakdown of performance at site level is also
These
of the
dementia screening
for patients over the age of 75 years that are
helpful
forincluded
more implementation
detailed internal
monitoring
of this tool
area.
admitted as an emergency (linked to the national Commissioning for Quality and Innovation (CQUIN) framework),
to identify patients with early signs of dementia and to enable speedier referral to mental health liaison teams
advice and support
that would
help to plan
facilitate
a more
effective
and timely
discharge, as
wellresults
as ensuring
TheforTrust-wide
dementia
delivery
that
was
generated
following
the
of the
that
correct
follow-up
care
was
received
with
signposting
and
improved
access
to
relevant
support
services
national dementia audit, included a number of actions to assist with the improvement
in
after discharge.
was to implement
dementia awareness
for relevant
front-line staff of
to the
Length
of Stay Another
(LOS) action
for patients
with dementia.
Thesetraining
included
implementation
raise awareness
of howtool
a person
dementia
may the
be affected
in a 75
hospital
environment
advice on how
dementia
screening
for with
patients
over
age of
years
that arewith
admitted
as an
to
improve
care
and
treatment.
This
was
also
aimed
to
have
a
positive
effect
on
patient
length
of
stays and
the
emergency (linked to the national Commissioning for Quality and Innovation
(CQUIN)
overall
patient
and
carer
experience.
Training
is
available
via
e-learning
packages
and
on
the
Diana,
Princess
of
framework), to identify patients with early signs of dementia and to enable speedier referral
Wales, Grimsby (DPoW) site, the local mental health provider has been delivering some classroom based sessions.
to mental health liaison teams for advice and support that would help to facilitate a more
Work is continuing to facilitate similar sessions on the other sites and in the community as well as other actions
effective
and timely discharge, as well as ensuring that correct follow-up care was received
focused on improving the care of patients with dementia, e.g. person-centred planning.
with signposting and improved access to relevant support services after discharge. Another
Haswas
the quality
indicator been
changedawareness
during the year
from that
in last year’s
(2011/12)staff
Quality
action
to implement
dementia
training
forsetrelevant
front-line
to raise
Account? of how a person with dementia may be affected in a hospital environment with
awareness
advice
on how
to improve
treatment.
Thisthewas
also
aimedperiod.
to have a positive effect
No, there
has been
no changecare
to thisand
quality
priority during
2012/13
reporting
on patient length of stays and the overall patient and carer experience. Training is available
for packages
changing theand
quality
for 2013/14:
Due toof
theWales,
limited nature
of benchmarking
via Rationale
e-learning
onpriority
the Diana,
Princess
Grimsby
(DPoW) data
site,with
the
which
to
compare
the
Trust
performance
with
peers,
the
value
of
this
indicator
was
limited.
Also
in
response
to is
local mental health provider has been delivering some classroom based sessions. Work
the national priority of dementia and the national Commissioning for Quality and Innovation (CQUIN) indicator,
Page 24 of 97
it was felt that inclusion of monthly performance with this CQUIN indicator regarding dementia would be a more
useful indicator going forward.
Directorate of Clinical and Quality Assurance, April 2013
19
Commissioning for Quality and Innovation (CQUIN) indicator, it was felt that inclusion of
monthly performance with this CQUIN indicator regarding dementia would be a more useful
indicator going forward.
Annual Quality Account 2012/13
2.1b PATIENT SAFETY
2.1bPatient safety
PS1 – MRSA
bacteraemia
Target:
Achieve
a level of noincidence
more than three MRSA Bacteraemias developing after 48
hours
into
the
inpatient
stay
(hospital
acquired).
Target: Achieve a level of no more than three MRSA
Bacteraemias developing after 48 hours into the inpatient
stay (hospital acquired).
Performance (April
2012 –2012
March–2013):
two2013):
cases two cases
Performance
(April
March
Previous performance:
Previous
performance:
2011/2012:
four cases of hospital
acquired
bacteraemia
(postMRSA
48 hours)
 2011/2012:
four cases
ofMRSA
hospital
acquired
bacteraemia
Hospital acquired MRSA bacteraemias (post 48 Hours)
5
4
3
2
2
2
1
1
1
0
0
2
0
1
0 0 0
0
0 0 0 0 0
1 1
0 0
1
0
1 1
0 0 0
0 0 0 0 0 0 0 0
Apr‐10
May‐10
Jun‐10
Jul‐10
Aug‐10
Sep‐10
Oct‐10
Nov‐10
Dec‐10
Jan‐11
Feb‐11
Mar‐11
Apr‐11
May‐11
Jun‐11
Jul‐11
Aug‐11
Sep‐11
Oct‐11
Nov‐11
Dec‐11
Jan‐12
Feb‐12
Mar‐12
Apr‐12
May‐12
Jun‐12
Jul‐12
Aug‐12
Sep‐12
Oct‐12
Nov‐12
Dec‐12
Jan‐13
Feb‐13
Mar‐13
Number of MRSA Bacteraemias (n=)
(post 48 hours)
 2010/2011:
ofMRSA
hospital
acquired
bacteraemia (post 48 hours)
2010/2011:
eight cases ofeight
hospitalcases
acquired
bacteraemia
(postMRSA
48 hours)
Source: Trust infection control database, information services team
Source: Trust infection control database, information services team
Comment: The above chart demonstrates the number of hospital acquired MRSA bacteraemias since April 2010.
The vertical axis demonstrates the number of hospital acquired MRSA bacteraemia identified within the Trust
whilst the horizontal
illustrateschart
the months
this informationthe
has been
identified
beginning
in April 2010.
Comment:
Theaxisabove
demonstrates
number
of from,
hospital
acquired
MRSA
During
eight
consecutive
months
in
2012/13
no
hospital
acquired
MRSA
bacteraemia
were
recorded.
bacteraemias since April 2010. The vertical axis demonstrates the number of hospital
acquired
MRSA
bacteraemia
identified
within
the that
Trust
the horizontal
axis illustrates
Has the quality
indicator
been changed
during the
year from
set whilst
in last year’s
(2011/12) Quality
the
months
this
information
has
been
identified
from,
beginning
in
April
2010.
During eight
Account?
consecutive months in 2012/13 no hospital acquired MRSA bacteraemia were recorded.
No, there has been no change to this quality priority during the 2012/13 reporting period.
Rationale for
changing
the quality
priority
for2013
2013/14: This indicator has not been replaced for
2012/13,
Directorate
of Clinical
and Quality
Assurance,
April
Page
25 of 97
however the threshold for MRSA bacteraemia has been reduced from three to 0.
20
Patient Safety
PS1 – MRSA bacteraemia incidence
three to 0.
PS2 – Clostridium difficile
Target: Achieve a level of no more than 34 hospital acquired C. Difficile cases over the
financial year 2011/12.
PS2 – Clostridium difficile
Target: Achieve a level of no more than 34 hospital acquired clostridium difficile cases over the financial year 2011/12.
Performance (April 2012 – March 2013): 37 cases
Performance (April 2012 – March 2013): 37 cases
Previous performance:
Previous performance:
 2011/2012:
2011/2012:
41of cases
hospital
acquired
Clostridium
41 cases
hospital of
acquired
clostridium
difficile
Infections. Difficile Infections.
 2010/2011: 43 cases of hospital acquired Clostridium Difficile Infections.
2010/2011: 43 cases of hospital acquired clostridium difficile Infections.
20
15
10
5
0
8
5
2
24 4
2
44
4 5 4
3
5
1
3
2
1
5
2
4
6
3
22
4 2
3
1 2
3
5 5
4
1
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Number of C Diff infections (n=)
Hospital acquired clostridium difficile infections
Source: Trust infection control database, information services team
Source: Trust infection control database, information services team
Comment: The above chart demonstrates the number of hospital acquired clostridium difficile infections (C Diff)
since April
2010. above
The vertical
axis illustrates
the numberthe
of hospital
acquired
infections
identified
Comment:
The
chart
demonstrates
number
of clostridium
hospitaldifficile
acquired
clostridium
within
the
Trust
whilst
the
horizontal
axis
illustrates
the
months
this
information
has
been
identified
from.
difficile infections (C Diff) since April 2010. The vertical axis illustrates the number of hospital
acquired
clostridium
difficile
the Trust
whilst
axis
As illustrated
in the above
chart,infections
the target foridentified
the year waswithin
not achieved.
This was
in largethe
part horizontal
due to the
increase
C Diff casesthis
associated
with Norovirus
and increased
bed from.
occupancy. Work is therefore underway with
illustrates
thein months
information
has been
identified
commissioners to try to maintain bed occupancy levels at 85 per cent or below. In addition, whilst there have
As illustrated
the aboveinchart,
theprescribing,
target for
the
year was
not achieved.
This was in large
been greatin
improvements
antibiotic
work
continues
to address
this issue.
part due
to the increase in C Diff cases associated with Norovirus and increased bed
Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality
occupancy.
Account? Work is therefore underway with commissioners to try to maintain bed
occupancy levels at 85% or below. In addition, whilst there have been great improvements
No, there has been no change to this quality priority during the 2012/13 reporting period.
in antibiotic prescribing, work continues to address this issue.
Rationale for changing the quality priority for 2013/14: This indicator has not been replaced for 2012/13,
however the threshold for clostridium difficile has been reduced from 34 to 30.
Has the quality indicator been changed during the year from that set in last years
(2011/12) Quality Account? No, there has been no change to this quality priority during the
2012/13 reporting period.
Rationale for changing the quality priority for 2013/14: This indicator has not been
replaced for 2012/13, however the threshold for clostridium difficile has been reduced from
34 to 30.
Directorate of Clinical and Quality Assurance, April 2013
Page 26 of 97
21
PS3 – Patient identification incidents
Annual Quality Account 2012/13
Target: To realise a five per cent reduction in patient identification incidents.
Achievement (April 2012 – January 2013): The following chart illustrates that the monthly
target
not been
met.
PS3 –has
Patient
identification
incidents
Target: To realise a five per cent reduction in patient identification incidents.
Achievement (April 2012 – January 2013): The following chart illustrates that the monthly target has not been met.
Trustwide
Average (Mean)
Jan‐13
Dec‐12
Nov‐12
Oct‐12
Sep‐12
Aug‐12
Jul‐12
Jun‐12
May‐12
Apr‐12
Mar‐12
Jan‐12
Feb‐12
Apr‐ May Jun‐ Jul‐ Aug Sep‐ Oct‐ Nov Dec Jan‐ Feb‐ Mar Apr‐ May Jun‐ Jul‐ Aug Sep‐ Oct‐ Nov Dec Jan‐
11 ‐11 11 11 ‐11 11 11 ‐11 ‐11 12 12 ‐12 12 ‐12 12 12 ‐12 12 12 ‐12 ‐12 13
20 14 13 7 21 11 10 17 12 24 31 29 21 26 27 25 18 19 30 23 16 20
20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20
Target ‐ 5% reduction
UCL
Dec‐11
Nov‐11
Oct‐11
Sep‐11
Aug‐11
Jul‐11
Jun‐11
May‐11
40
35
30
25
20
15
10
5
0
Apr‐11
Number of Patient identification incidents (n=) Statistical Proces Control (SPC) ‐ Trust 5% planned reduction in patient identification incidents
45
18 18 18 18 18 18 18 18 18 18 18 18 18
42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42
Source: DATIX, clinical and quality assurance team
Source: DATIX, clinical and quality assurance team
Comment: The above chart demonstrates the number of patient identification
Comment:
above
demonstrates
the number
of patient identification incidents
incidents withinThe
the Trust.
This ischart
expressed
in an SPC or Statistical
Process Control
on:Chart
DATIXwhich
within
the allows
Trust.
Thisprocess
is expressed
in an SPC
or Statistical
Process Focus
Control
Chart which
routine
data to be calculated
and interpreted
using
statistical
rules.
The
mean
line
demonstrates
the
level
of
average
performance
whilst
allows routine process data to be calculated and interpreted using statistical
rules. Theof mean
A core component
quality within the
the upper
control limit or
UCL
sets aof
statistically
calculated
maximumwhilst
level ofthe
variation
Trust islimit
the principle
to ‘do
no harm’ to
line
demonstrates
the
level
average
performance
upper control
or UCL
sets
would be expected
within this
process. Alsolevel
plottedof
is the
target reduction
or service
users.this
athatstatistically
calculated
maximum
variation
that would be patients
expected
within
being aimed for on a monthly basis. This was calculated from information from the
Healthcare
however
high risk industry.
process.
Also plotted is the target reduction being aimed for on a monthly
basis.
Thisis awas
beginning of April 2011. The average performance for this area was 20 therefore a five
One of the Trust’s priorities therefore is to
calculated
from
information
from
the
beginning
of
per cent reduction target has been set, which equates to a monthly target of 18.
manage this risk. One way of doing this
April 2011. The average performance for this area
is using software such as DATIX which
Patient misidentification is part of the Trust Learning Lessons Action Plan, a
was
20
therefore
a
five
per
cent
reduction
target
provides the Trust access to incident
number of interventions have been implemented to reduce the number of patient
reporting and adverse event reporting.
has
been
set,
which
equates
to
a
monthly
target
of
misidentification incidents, including articles in the Learning Lessons newsletter,
Focus on: DATIX
From this system, the Trust is able to
18.
internal safety alerts, inclusion of Patient Identification Policy in the local induction
monitor,
report
and the
more importantly
A core component
of quality
within
checklist. Further targeted campaigns are planned with the risk and governance
learntofrom
adverse
Patient
misidentification is part of the Trust
Trust is the principle
‘do any
no harm’
to incidents to
facilitators during 2013/14.
prevent
them from re-occurring.
patients
or
service
users.
Learning Lessons Action Plan, a number of
Additionally, further work has been undertaken to determine the difference between
interventions
have been implemented to reduce
Healthcare however is a high risk
the situations and contexts of internally reported patient identification incidents. In
industry. One of the Trust’s priorities
the
number
of
patient
misidentification
incidents,
particular this has been focussed around understanding the difference between those
therefore is to manage this risk. One
including
articles
in
the
Learning
Lessons
reported as a result of diagnostic investigation vs. non-diagnostic incidents.
way of doing this is using software
newsletter, internal safety alerts, inclusion of
such
DATIX
which provides
the
In support of the work undertaken within the Trust, it was highlighted that not
all as
patient
identification
incidents
Patient
Identification
Policy
in
the
local
induction
Trust
access
to
incident
reporting
were attributable to the Trust. In some cases, although the Trust has reported the incident, the source has been and
checklist.
Further
targeted
campaigns
are been
planned
adverse
reporting.
From this
external to the
organisation,
for instance
incidents have
reported by Path
Links event
that relate
to samples
system,
the
Trust
is
able
to monitor,
with
the
risk
and
governance
facilitators
during
received from external sources which are incorrectly labelled with Patient Identifiers missing or incorrect.
report
and
more
importantly
learn from
2013/14.
Additionally, further work has been undertaken to
determine the difference between the situations
and contexts of internally reported patient
22
Directorate of Clinical and Quality Assurance, April 2013
any adverse incidents to prevent them
from re-occurring.
Page 27 of 97
Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality
Account?
No, there has been no change to this quality priority during the 2012/13 reporting period.
Rationale for changing quality priority for 2013/14: This indicator is now monitored on a monthly basis
by individual clinical governance groups and the learning lessons group. Systems have now been put in place that
prevents diagnostic tests to be undertaken without an NHS number being present. Any externally identified problems
with patient identifiers are escalated to the relevant external bodies for their notification and root cause analysis.
PS4 – Patient medication incidents
Target: To realise a downward trajectory in reported incidents where patients are prescribed penicillin where there
is a documented penicillin allergy.
the quality indicator been changed during the year from that set in last year’s (2011/12) Quality
PS5 – Has
Patient
falls
Account?
Yes,
following
the cent
monthly
quality report,
it was
felt that this
indicator
not relevant
for monitoring
Target:
To
realisea review
a fiveofper
reduction
in the
number
of falls
perwas
1,000
bed days.
in the monthly report as it is closely monitored by the safer medications group.
Achievement
(April
2012the–quality
January
2013):
Performance
since April 2012 has not met the
Rationale for
changing
priority
for 2013/14:
As clarified above.
target reduction set.
PS5 – Patient falls
Target: To realise a five per cent reduction in the number of falls per 1,000 bed days.
Statistical Process Control (SPC) ‐ Trust (preventable and non‐preventable) falls per 1,000 bed days
Achievement (April 2012 – January 2013): Performance since April 2012 has not met the target reduction set.
12.00
189
170
8.00
157
6.00
180
163 159 178
149 156 165152 161
150
157
150
150 149
137
146
133
124
175
4.00
2.00
0.00
Apr‐10
May‐10
Jun‐10
Jul‐10
Aug‐10
Sep‐10
Oct‐10
Nov‐10
Dec‐10
Jan‐11
Feb‐11
Mar‐11
Apr‐11
May‐11
Jun‐11
Jul‐11
Aug‐11
Sep‐11
Oct‐11
Nov‐11
Dec‐11
Jan‐12
Feb‐12
Mar‐12
Apr‐12
May‐12
Jun‐12
Jul‐12
Aug‐12
Sep‐12
Oct‐12
Nov‐12
Dec‐12
Jan‐13
Number of Patient falls per 1000 bed days (n=) 10.00
Falls per 1,000 bd
Ap Ma
Au Se Oc No De
Fe Ma Ap Ma
Au Se Oc No De
Fe Ma Ap Ma
Au Se Oc No De
Jun Jul‐
Jan
Jun Jul‐
Jan
Jun Jul‐
Jan
r‐ y‐
g‐ p‐ t‐ v‐ c‐
b‐ r‐ r‐ y‐
g‐ p‐ t‐ v‐ c‐
b‐ r‐ r‐ y‐
g‐ p‐ t‐ v‐ c‐
‐10 10
‐11
‐11 11
‐12
‐12 12
‐13
10 10
10 10 10 10 10
11 11 11 11
11 11 11 11 11
12 12 12 12
12 12 12 12 12
6.1 8.2 7.4 8.2 7.4 7.4 7.1 6.7 8.5 8.5 7.9 8.2 7.8 8.5 9.5 6.8 7.8 8.4 8.3 7.9 8.3 7.3 6.4 6.8 7.3 6.7 8.1 8.4 8.3 7.7 5.7 7.6 8.2 9.1
Mean 10/11
7.6 7.6 7.6 7.6 7.6 7.6 7.6 7.6 7.6 7.6 7.6 7.6
Mean 11/12
7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8
Target 5% reduction
7.4 7.4 7.4 7.4 7.4 7.4 7.4 7.4 7.4 7.4
LCL
5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0
UCL
10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10.
clinical
and quality
assurance
team
Source:Source:
DATIX,DATIX,
clinical
and quality
assurance
team
Comment: The above chart illustrates the number of preventable and non-preventable patient falls per 1,000
bed days. The information is expressed in a Statistical Process Control (SPC) chart which allows for routine process
data to be
interpreted
statistical
rules, as expressed
by the upper
control limit (UCL)
lower control limit
Comment:
The
aboveusing
chart
illustrates
the number
of preventable
andthenon-preventable
(LCL)
and
the
mean.
Also
plotted
is
the
target
reduction
being
aimed
for,
in
this
case
a
five
per
cent reduction
patient falls per 1,000 bed days. The information is expressed in a Statistical Process
Control
(SPC) chart which allows for routine process data to be interpreted using statistical rules, as
expressed by the upper control limit (UCL) the lower control limit (LCL) and the mean. Also
23which
plotted is the target reduction being aimed for, in this case a five per cent reduction
was based on the average performance during March 2011 and April 2012. A five per cent
Annual Quality Account 2012/13
which was based on the average performance during March 2011 and April 2012. A five per cent reduction aimed
for per month was therefore 7.4 falls per 1,000 bed days.
NB: The data labels within the above chart refer to the actual number of falls recorded per month. The vertical
axis relates to falls per 1,000 bed days.
As a result of the previous work undertaken in this area, the DATIX system is now able to provide a single
notification on all single falls allowing the lead quality matron to go to that ward immediately with the intention
of preventing repeat falls. For ward based falls, a thematic analysis is performed to identify what additional
actions are required in these areas to ensure lessons are learnt.
An additional factor which has potentially contributed to increased reporting of falls has been the acute pressures
on beds which has put additional pressure on the system and has lead in some cases to a number of ward
transfers and in some cases outliers on non-specialty wards.
Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality
Account? No, there has been no change to this quality priority during the 2012/13 reporting period.
Rationale for changing the quality priority for 2013/14: Patient falls have represented a significant priority
for the Trust during this financial year. The above falls indicator, although changed, still keeps the focus on this
important area. The rationale for the change is to ensure the Commissioning for Quality and Innovation (CQUIN)
indicator relating to falls within the NHS Safety Thermometer is appropriately monitored. This refocusing of the
indicator allows for the Trust to focus on reducing the number of preventable fallers. This level of specificity has
not been available before.
24
News release:
Steps being taken to reduce patient falls
Steps are being taken to help reduce the number of patient falls at the Northern Lincolnshire and Goole
Hospitals NHS Foundation Trust.
Bright red slipper socks are being rolled out on the wards at the Trust’s three hospitals in Goole, Grimsby
and Scunthorpe.
The socks are being handed out to patients who have been identified as being at high risk of slips, trips
and falls.
The socks have extra grip on them but they also have another purpose, as Melanie Sharp, quality matron
at the Trust, explains. She said: “We need and expect all of our nursing staff to be able to identify those
patients who are at risk of falling. With the socks being bright red it’s a clear indication which patients on
the ward are potential fallers.”
Previously the Trust has used red wrist bands to help identify high risk patients, but these were used for a
number of other risks, including allergies and so it wasn’t immediately obvious that someone was at a high
risk of falling.
The consequences of falling can range from distress and loss of confidence, to injuries that cause pain
and suffering, loss of independence and, occasionally, death. In addition to the human cost there is also a
financial cost, due to things like a resulting longer stay in hospital.
One of the first areas to use the socks is the Medical Admissions Unit (MAU) at Grimsby’s Diana, Princess of
Wales Hospital, which was chosen because patients tend to go on to other wards from there. The unit had
been using a different brand of slipper socks for about six months before receiving the new red socks.
If a patient comes into the Trust having previously fallen, whether that be at home or during a previous
hospital stay, they are put straight onto the hourly slips, trips and fall pathway and are given a pair of the
red socks. The pathway was designed by a health care assistant at the Trust and involves a check list which
looks at a range of things from whether the patient can reach the call bell, if their glasses are clean, the
bed is at the lowest possible height and if they wearing the correct footwear. As well as helping to keep
patients safe the socks are also cost effective as they come in one size fits all, making them less expensive
than previous socks purchased.
Patient Ian Porteous has been wearing the socks for a few days after he fell when he collapsed in hospital.
He said: “I think they are a marvellous idea; they really grip and they’re comfy. I can’t really walk but they
give me extra grip when I stand up. I didn’t realise they were red so that staff could keep an eye out for us,
that’s a good idea.”
All patients have their risk of falling assessed within 24 hours of being admitted to hospital. Other actions
taken by the Trust to reduce slips, trips and falls include:
••
All falls incidents are monitored by the lead quality matron
••
A full investigation takes place for any repeat fall or a fall that leads to moderate or severe injury,
with lessons learned being shared between wards.
••
Dedicated training has been provided to staff around falls risk assessment, falls awareness, falls
prevention and steps to take after a fall
••
New electronic profiling beds with safety sides have been introduced
••
Information for patients and carers has been produced on how to reduce the risk of falling.
The red socks are kept by the patient after they leave hospital so they can continue to be safe out in the
community, whether that is at home or in a nursing or care home.
25
Annual Quality Account 2012/13
PS6 – Repeat fallers
Target: To realise a five per cent reduction in the number of repeat fallers per 1,000 bed
days.
PS6 – Repeat fallers
Target: To realise a(April
five per cent
reduction
in the number
repeatchart
fallers below
per 1,000illustrates
bed days. that performance in
Achievement
2012
– January
2013):ofThe
September,
October,
November
December
reduced
towards inthe
monthly
target set.
Achievement (April
2012 – January
2013): and
The chart
below illustrates
that performance
September,
October,
November and
towards
the monthly
set. However,
in January,
rose
to 1.25met.
and at
However,
in December
January,reduced
this rose
to 1.25
and attarget
present
the target
is stillthis
not
being
Number of repeat fallers per 1000 bed days (n=) present the target is still not being met.
Statistical Process Control (SPC) ‐ Trust repeat (preventable and non‐
preventable) fallers per 1,000 bed days
2.00
1.50
21 20
34
25 27
23
1.00
15
0.50
29
23 23 27 22
24
20 20
16 20
0.00
Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐ Mar Apr‐ May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐
11 11 11 11 12 12 ‐12 12 ‐12 12 12 12 12 12 12 12 13
Repeat falls per 1000 bd 1.08 1.04 1.26 1.26 0.73 0.77 0.91 0.97 0.92 1.20 1.59 1.40 1.10 1.06 1.17 1.13 1.25
Mean
1.10 1.10 1.10 1.10 1.10 1.10 1.10 1.10 1.10 1.10 1.10 1.10 1.10 1.10 1.10 1.10 1.10
Target 5% reduction
0.96 0.96 0.96 0.96 0.96 0.96 0.96 0.96 0.96 0.96
LCL
0.40 0.40 0.40 0.40 0.40 0.40 0.40 0.40 0.40 0.40 0.40 0.40 0.40 0.40 0.40 0.40 0.40
UCL
1.79 1.79 1.79 1.79 1.79 1.79 1.79 1.79 1.79 1.79 1.79 1.79 1.79 1.79 1.79 1.79 1.79
Data Source:
clinical
and
quality
assurance
teamteam
Data
Source:DATIX,
DATIX,
clinical
and
quality
assurance
NB: The data labels within the above chart refer to the actual number of repeat falls recorded per month. The
vertical axis relates to falls per 1,000 bed days.
NB: The data labels within the above chart refer to the actual number of repeat falls
Comment: The
above
chart illustrates
the number
preventable
non-preventable
patients
having repeat
recorded
per
month.
The vertical
axisofrelates
to and
falls
per 1,000 bed
days.
falls per 1,000 bed days. The information is expressed in a Statistical Process Control (SPC) chart which allows for
routine process data to be interpreted using statistical rules, as expressed by the upper control limit (UCL) the
Comment:
The
above
illustrates
thetarget
number
of being
preventable
non-preventable
lower control limit
(LCL)
and the chart
mean. Also
plotted is the
reduction
aimed for, inand
this case
a five per
cent reduction
whichrepeat
was based
on the
period of September
2011 andin
March
patients
having
falls
peraverage
1,000performance
bed days.during
The the
information
is expressed
a Statistical
2012.
A
five
per
cent
reduction
aimed
for
per
month
was
therefore
0.96
repeat
falls
per
1,000
bed
days.
Process Control (SPC) chart which allows for routine process data to be interpreted using
statistical
as expressed
by the
upper
(UCL)
thetwo
lower
control
As a result ofrules,
this focussed
work, the number
of falls
is nowcontrol
able to belimit
broken
down into
categories
– (1)limit (LCL)
the un-preventable
fall and
(2) the preventable
fall. As
a result of this
greater
specificity,
thethis
leadcase
qualitya five per cent
and
the mean. Also
plotted
is the target
reduction
being
aimed
for, in
matron is ablewhich
to still further
focus heron
efforts
those areasperformance
within the Trust that
requirethe
targeted
support
and
reduction
was based
theonaverage
during
period
of September
improvement.
Due
to
this
focus,
the
reporting
of
falls
using
the
DATIX
incident
system
has
also
improved
and
2011 and March 2012. A five per cent reduction aimed for per month was therefore 0.96
therefore increased the number of reported falls. The Trust positively encourages the reporting of any incident or
repeat
falls per 1,000 bed days.
potential incident as pro-active work can then be undertaken to learn lessons and prevent re-occurrence.
Hasathe
quality
been changed
the year from
thatis
setnow
in last
year’s
Quality
As
result
ofindicator
this focussed
work,during
the number
of falls
able
to(2011/12)
be broken
down into two
Account?
categories – (1) the un-preventable fall and (2) the preventable fall. As a result of this greater
Yes, in the 2011/12
Trust setis
outable
the following
a quality focus
priority for
specificity,
thequality
lead account,
qualitythe
matron
to stillasfurther
her2012/13:
efforts on those areas
within
the
Trust
that
require
targeted
support
and
improvement.
Due
this focus, the
“To realise a five per cent reduction in the number of repeat fallers with a downward trajectory forto
wards
reporting
fallsabove
using
DATIX
incident
has also improved and therefore increased
identified asof
falling
thethe
upper
confidence
level insystem
the SPC chart”
the number of reported falls. The Trust positively encourages the reporting of any incident or
potential incident as pro-active work can then be undertaken to learn lessons and prevent reoccurrence.
26
Directorate of Clinical and Quality Assurance, April 2013
Page 31 of 97
On assessing this indicator in more detail, it was found to be a flawed quality indicator as the number of repeat
fallers on a ward would need to be unrealistically high for the ward’s performance to fall outside of the control
limits on the SPC chart. Therefore the decision was taken to amend this indicator to allow for a more useful quality
indicator to monitor individual ward performance.
Rationale for changing the quality priority for 2013/14: Patient falls have represented a significant priority
for the Trust during this financial year. The above falls indicator, although changed, still keeps the focus on this
important area. The rationale for the change is to ensure the Commissioning for Quality and Innovation (CQUIN)
indicator relating to falls within the NHS Safety Thermometer is appropriately monitored. The focussed work
undertaken for this indicator allows the Trust to focus on reducing the number of preventable fallers. This level of
specificity has not been available before.
PS7 – Falls Root Cause Analysis (RCA)
Target: To achieve 100% compliance with undertaking root cause analysis for repeat fallers from April 2012
Achievement (April 2012 – January 2013): At the beginning of the financial year data recording issues posed a
problem in accurately measuring this indicator. From October these issues were permanently resolved resulting
in four consecutive months of compliance with this target.
Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
21
Number of Repeat Fallers
20
25
27
15
16
20
20
20
23
34
29
23
23
27
22
Jan
24
Root Cause Analysis undertaken 2
3
5
8
5
7
9
8
6 14 22 21 21 23 27 22 24
for Repeat Fallers
Average
10% 15% 20% 30% 33% 44% 45% 40% 30% 50% 65% 72% 91% 100% 100% 100% 100%
Data Source: DATIX, clinical and quality assurance team, as reported on February 5 2013
Comment: The above table illustrates the numbers of patients having been identified as having a repeat fall
per month and of these, the number having had a root cause analysis undertaken to assess if any trends are
identifiable to enable remedial action to be taken.
Root Cause Analysis (RCA) outcomes – preventable falls
The lead quality matron is supporting proactive work to prevent falls occurring. As part of the RCA work
undertaken as a result of a repeat fall, an effort has been made to determine the numbers of potentially
preventable falls. This data is illustrated below.
Sept Oct Nov Dec Jan
Number of Repeat Fallers
Preventable
Non - Preventable
Feb Mar Apr May June July Aug Sept Oct Nov Dec
Jan
21
20
25
27
15
16
20
20
20
23
34
29
23
23
27
22
24
-
-
-
-
-
-
-
-
-
-
-
8
5
3
7
3
6
-
-
-
-
-
-
-
-
-
-
-
21
18
20
20
19
18
Data Source: RCA records held by quality matron
Comment: This table illustrates that in January 75 per cent of all repeat falls were non-preventable. The remaining
25 per cent that were considered to be preventable are then focussed on by the quality matron with the lead for
falls and ward specific learning points and interventions are determined with ward staff. This degree of specificity
has not been available in previous years, therefore this provides the Trust very useable information with which it
can actively focus and work to reduce the number of preventable falls within the organisation.
27
Annual Quality Account 2012/13
Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality
Account?
undertaken
as anoresult
fallers,
willthe
continue
to be monitored
in collaboration with
No, there has been
changeof
to all
thisrepeat
quality priority
during
2012/13 reporting
period.
the findings from this falls related quality priority.
Rationale for changing the quality priority for 2013/14: Patient falls have represented a significant priority
for the Trust during this financial year. The above falls indicator, although changed, still keeps the focus on this
important area. The rationale for the change is to ensure the Commissioning for Quality and Innovation (CQUIN)
PS8
– Pressure ulcers
indicator relating to falls within the NHS Safety Thermometer is appropriately monitored. In addition to this, the
number of avoidable falls, as determined from the focussed root cause analysis work undertaken as a result of all
repeat fallers, will continue to be monitored in collaboration with the findings from this falls related quality priority.
Target – To realise a five per cent reduction in the number of hospital acquired
pressure ulcers per 1,000 bed days
PS8 – Pressure ulcers
Achievement (April 2012 – February 2013): The table below illustrates that this indicator
Target – To realise a five per cent reduction in the number of hospital acquired pressure ulcers per 1,000 bed days
has
not been met.
Achievement (April 2012 – February 2013): The table below illustrates that this indicator has not been met.
Statistical Process Control (SPC) ‐ NLAG pressure ulcers (avoidable and unavoidable) per 1,000 bed days
2.50
44
2.00
1.50
33
28
24
1.00
0.00
16
15
1413
12
12
11
10
10
17
1616
9
32
27
29
13
Jul‐10
Aug‐10
Sep‐10
Oct‐10
Nov‐10
Dec‐10
Jan‐11
Feb‐11
Mar‐11
Apr‐11
May‐11
Jun‐11
Jul‐11
Aug‐11
Sep‐11
Oct‐11
Nov‐11
Dec‐11
Jan‐12
Feb‐12
Mar‐12
Apr‐12
May‐12
Jun‐12
Jul‐12
Aug‐12
Sep‐12
Oct‐12
Nov‐12
Dec‐12
Jan‐13
Feb‐13
0.50
19
23 23
17 18
31
24
PU per 1,000 bd
Au
No De
Ma
Ma
Au
No De
Au
No De
Ma
Ma
Jun Jul‐
Sep Oct
Jan Feb
Apr
Jun Jul‐
Sep Oct
Jan Feb
Jul‐
Sep Oct
Jan Feb
Apr
g‐
v‐ c‐
r‐
y‐
g‐
v‐ c‐
g‐
v‐ c‐
r‐
y‐
‐11 11
‐11 ‐11
‐12 ‐12
‐12
‐12 12
‐12 ‐12
‐13 ‐13
10
‐10 ‐10
‐11 ‐11
‐11
11
11 11
12
12
12
12 12
10
10 10
11
11
0.4 0.8 0.4 1.0 0.4 0.6 0.6 0.5 0.4 0.7 0.5 1.3 0.7 1.2 0.5 0.9 0.4 0.7 0.7 0.6 0.7 1.6 0.7 1.2 0.8 1.1 1.2 1.4 1.6 1.3 1.2 2.1
Average (mean)
0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8
Average (Q1 '11)
Target 5% reduction
UCL
0.9 0.9 0.9
0.8 0.8 0.8 0.8 0.8 0.8 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6
1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9
Source: July
July 2010
2013:
Information
services
team, intranet
February
Source:
2010– January
– January
2013:
Information
services
team, collated
intranetdata,
collated
data,2013:
February
2013:
DATIX,and
clinical
and assurance
quality assurance
DATIX, clinical
quality
team team
Comment: The above chart illustrates the number of pressure ulcers per 1,000 bed days, including both
avoidable and The
unavoidable.
information
is expressed
in a Statistical
Control
(SPC) chart
Comment:
aboveThe
chart
illustrates
the number
of Process
pressure
ulcers
per which
1,000allows
bed days,
for
routine
process
data
to
be
interpreted
using
statistical
rules,
as
expressed
by
the
upper
control
limit
(UCL)
the
including both avoidable and unavoidable. The information is expressed in a Statistical
lower
control
limit
(LCL)
and
the
mean.
Also
plotted
is
the
target
reduction
being
aimed
for,
in
this
case
a
five
per
Process Control (SPC) chart which allows for routine process data to be interpreted using
cent reduction.
statistical rules, as expressed by the upper control limit (UCL) the lower control limit (LCL)
NB: The
labelsAlso
within
the above
above refer
to the actual
number
of hospital
pressure
ulcers
and
thedata
mean.
plotted
is chart
the target
reduction
being
aimed
for, inacquired
this case
a five
per cent
recorded
per
month.
The
vertical
axis
refers
to
the
number
per
1,000
bed
days.
reduction.
NB: The data labels within the above chart above refer to the actual number of
hospital acquired pressure ulcers recorded per month. The vertical axis refers to the
number
28per 1,000 bed days.
The quality matron with the lead for pressure ulcers has been actively reviewing the different
1. DATIX Incident Reporting System
2. Root Cause Analysis (RCA) records kept by lead quality matron.
As a result
of this work, the above chart illustrates February’s data, the first to be reported
The quality matron with the lead for pressure ulcers has been actively reviewing the different data sources within
from DATIX.
move
to DATIX
enables
theonlead
quality
matron
to oversee
thesources
numbers
the TrustThe
that are
currently
supplying
information
pressure
ulcers.
There were
three primary
of dataof
hospitalwhich
acquired
pressure
on an quality
ongoing
basis
and
accordingly.
inform reports
suchulcers
as the monthly
report.
These
havereact
been reviewed
and reduced to two, namely:
1.
DATIX Incident Reporting System
The move to reporting and monitoring this area from one source, DATIX, has resulted in a
Cause Analysis (RCA) records kept by lead quality matron.
higher 2.than Root
previously
reported incidence of hospital acquired pressure ulcers. From a
As
a
result
of
this
work,
the above
February’s
data, the positions
first to be reported
from DATIX.
move
review of this most recent
datachart
andillustrates
previously
reported
it appears
thatThethese
to
DATIX
enables
the
lead
quality
matron
to
oversee
the
numbers
of
hospital
acquired
pressure
ulcers
on
an
inconsistencies may have been a result of previously under reporting hospital acquired
ongoing basis and react accordingly.
pressure
ulcers. As a result of this work on the data from DATIX and the monitoring
The move
reporting
monitoring
this area from
source,
DATIX, has resulted
in afigure
higher than
previously
processes
that tohave
nowand
been
established,
the one
Trust
is confident
that the
as reported
reported
incidence
of
hospital
acquired
pressure
ulcers.
From
a
review
of
this
most
recent
data
and
previously
in DATIX is the correct one allowing for proactive work to be undertaken in an attempt to
positions it appears that these inconsistencies may have been a result of previously under reporting
improvereported
the reported
position in future months.
hospital acquired pressure ulcers. As a result of this work on the data from DATIX and the monitoring processes
that have now been established, the Trust is confident that the figure as reported in DATIX is the correct one
Anotherallowing
objective
behindwork
centralising
the data
sourcetoused
forthe
pressure
ulcer monitoring
and
for proactive
to be undertaken
in an attempt
improve
reported position
in future months.
reporting is to focus on reducing the number of avoidable pressure ulcers. Currently the
Another objective behind centralising the data source used for pressure ulcer monitoring and reporting is to
distinction
between avoidable and un-avoidable pressure ulcers is being made as a result of
focus on reducing the number of avoidable pressure ulcers. Currently the distinction between avoidable and
the rootun-avoidable
cause analysis
work isfor
grade
andof the
fourroot
pressure
ulcers
This
is and
onlyfour
the
pressure ulcers
being
madethree
as a result
cause analysis
workonly.
for grade
three
first step,
with
plans
being
made
assess
allbeing
hospital
pressure
ulcers
pressure
ulcers
only. This
is only
the firstto
step,
with plans
made toacquired
assess all hospital
acquired
pressureand
ulcersifand
determine
if they were avoidable
or not.
In future
process for
threethree
and four
ulcers
determine
they
were avoidable
or not. In
future
onceonce
thetheprocess
forgrades
grades
and
four
is
sustained,
this
will
be
replicated
for
grade
two.
At
that
point,
the
reporting
within
the
monthly
quality
report
ulcers is sustained, this will be replicated for grade two. At that point, the reporting within the
focus onreport
those pressure
ulcerson
considered
to be avoidable
and considered
an improvement
will be used
monthlywillquality
will focus
those pressure
ulcers
totrajectory
be avoidable
andtoan
measure this area on an ongoing basis.
improvement trajectory will be used to measure this area on an ongoing basis.
Hospital
acquired
pressure
ulcersulcers
by grade
Hospital
acquired
pressure
by grade
Pressure ulcers by grade (avoidable and unavoidable) ‐ hospital acquired only
40
35
30
25
20
15
10
5
0
Apr‐12May‐12 Jun‐12 Jul‐12 Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13
Grade 2
Apr‐12 May‐12 Jun‐12 Jul‐12 Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13
30
15
19
13
21
20
28
29
23
28
34
Grade 3
2
2
7
3
3
2
2
3
6
3
6
Grade 4
0
0
0
0
1
0
0
0
0
1
4
Grade not recorded
1
0
0
3
0
2
1
1
0
0
0
Source: April 2012 – January 2013: Information services team, intranet collated data, February 2013: Source: April 2012
– January
2013:
Information
team, intranet collated data, February 2013:
DATIX,
clinical and
quality
assurance services
team
DATIX, clinical and quality assurance team
Please note that some patients have multiple pressure ulcers at different grades, therefore, the numbers detailed
within this chart may be higher than the number of patients detailed within the other pressure ulcer charts/table.
Please note that some patients have multiple pressure ulcers at different grades,
Comment:
The above chart
illustrateswithin
the number
acquired
ulcers
by grades
two, three of
therefore,
the numbers
detailed
thisof hospital
chart may
bepressure
higher
than
the number
and
four.
The
vertical
axis
illustrates
the
number
of
pressure
ulcers
whilst
the
horizontal
axis
demonstrates
the
patients detailed within the other pressure ulcer charts/table.
months over which this indicator has been measured, starting in April 2012.
29
Annual Quality Account 2012/13
Root Cause Analysis (RCA) outcomes - avoidable grade three and four pressure
ulcers
As a result of the focussed work undertaken around this area, more specific data is now available to the Trust
demonstrating the breakdown of patients with grade three and four pressure ulcers into the avoidable and
unavoidable. Work is now underway to refocusing all hospital acquired pressure ulcer data to be available in this
format.
The information below is taken from records kept by the lead quality matron as a result of the root cause analysis
work taking place for patients with grades three and four pressure ulcers. This data is more comprehensive
than the information collected via the intranet by a variety of ward staff as this is developed through close
collaboration between the lead quality matron and the tissue viability team. As a result you will notice a disparity
between the numbers of patients with grades three and four pressure ulcers below compared to the chart
above. Work is ongoing to ensure all pressure ulcer data in future comes from one source to ensure accurate data
recording/reporting.
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Number of grade three and four
pressure ulcers
7
3
6
5
3
12
13
Avoidable
4
0
2
2
2
3
3
Unavoidable
3
3
4
3
1
9
10
Source: Root Cause Analysis (RCA) records kept by lead quality matron
Comment: This table illustrates that for February 77 per cent of all grade three and four pressure ulcers were
unavoidable. The remaining 23 per cent were considered avoidable. These are then focussed on by the quality
matron with the lead for pressure ulcers.
Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality
Account?
No, there has been no change to this quality priority during the 2012/13 reporting period.
Rationale for changing the quality priority for 2013/14: Pressure ulcers have represented a significant priority
for the Trust during this financial year. For 2013/14 the pressure ulcers indicator will be linked to a reduction in the
number of avoidable pressure ulcers as determined from the focussed root cause analysis work undertaken as a
result of a grade three or four pressure ulcer.
PS9 – Pressure ulcers for specific conditions
Target – To achieve a downward trajectory in the number of pressure ulcers for patients with the
following conditions: Parkinson’s, hypothermia, spinal cord compression, dementia and fractured neck
of femur.
Has the quality indicator been changed during the year from that set in last years (2011/12) Quality
Account? Yes, as a result of moving away from reporting this area from any source other than DATIX, the rate
of pressure ulcers in these specific conditions is unavailable as a result of the amended information reporting
structures.
Rationale for changing the quality priority for 2013/14: For 2013/14 the pressure ulcers indicator will be linked
to a focussed reduction in the number of avoidable pressure ulcers as determined from the focussed root cause
analysis work undertaken as a result of a grade three or four pressure ulcer.
30
determined from the focussed root cause analysis work undertaken as a result of a grade
three or four pressure ulcer.
2.1c PATIENT EXPERIENCE
Target: 85% or more of patients to be satisfied with Trust services.
PE1 – Overall satisfaction with Trust services
Achievement
(April
2012
2013):
chartservices.
below demonstrates that this target
Target: 85 per
cent or
more–ofFebruary
patients to be
satisfiedThe
with Trust
has been met, with six consecutive months above the mean set within the SPC chart.
Achievement (April 2012 – February 2013): The chart below demonstrates that this target has been met, with
six consecutive months above the mean set within the SPC chart.
Statistical Process Control (SPC) ‐ overall satisfaction with Trust services
105
95
90
85
80
75
May‐10
Jun‐10
Jul‐10
Aug‐10
Sep‐10
Oct‐10
Nov‐10
Dec‐10
Jan‐11
Feb‐11
Mar‐11
Apr‐11
May‐11
Jun‐11
Jul‐11
Aug‐11
Sep‐11
Oct‐11
Nov‐11
Dec‐11
Jan‐12
Feb‐12
Mar‐12
Apr‐12
May‐12
Jun‐12
Jul‐12
Aug‐12
Sep‐12
Oct‐12
Nov‐12
Dec‐12
Jan‐13
Feb‐13
Percentage satisfaction (%) 100
Source: Menu card survey, membership office
Source: Menu card survey, membership office
Comment: The above chart demonstrates on the vertical axis the percentage satisfaction and on the horizontal
axis the months over which this indicator has been measured. From September 2012 a run of six consecutive
months The
of above
the mean
performance
have beenon
identified.
Comment:
above
chart
demonstrates
the vertical axis the percentage satisfaction
and onHasthe
axisbeen
the changed
monthsduring
over the
which
this that
indicator
has
been
measured.
thehorizontal
quality indicator
year from
set in last
year’s
(2011/12)
Quality From
Account?
September
2012 a run of six consecutive months of above the mean performance have been
identified.
No, there has been no change to this quality priority during the 2012/13 reporting period.
Rationale for changing the quality priority for 2013/14: The Trust has consistently performed well with this
indicator. As a result of this the patient experience indicator will be refocused to the national use of the friends
and family question ensuring that patient experience remains a quality priority.
Directorate of Clinical and Quality Assurance, April 2013
Page 37 of 97
31
Patient Experience
PE1 –2.1cPatient
Overall satisfaction
with Trust services
experience
Annual Quality Account 2012/13
News release:
15 Steps Challenge putting the focus on care
A new initiative has been launched focusing on what good quality care looks, sounds and feels like
through the eyes of patients and visitors.
The 15 Steps Challenge has been introduced at Grimsby, Scunthorpe and Goole hospitals and involves
wards and departments receiving unannounced visits by a small team of people, including a non-medical
person.
The challenge, which has been designed by the NHS Institute for Innovation and Improvement, aims to
capture what good quality care looks, sounds and feels like. The idea came from a parent who said “I can
tell what kind of care my daughter if going to get within 15 steps of walking on to a ward.”
Dr Karen Dunderdale, chief nurse, said: “First impressions count. When someone walks onto a ward for the
first time I want those first 15 steps to inspire confidence and trust in the care they, or their loved one, is
going to receive.
“The challenge, which supplements our more formal ward review process, looks at walking onto a ward
from a patient’s perspective and provides them with a voice.”
The purpose of the challenge is to:
••
Help staff, patients, service users and others to work together to identify improvements that can
enhance the patient or service user experience.
••
Provide a way of understanding patients’ and service users’ first impressions more clearly.
••
Provide a method of creating positive improvements and dialogue about the quality of care.
Quality matron Diane Hughes, who is rolling out the challenge, said: “We know what good care should look
and feel like from a healthcare perspective, but this challenge gives us the opportunity to take a step back
and look at what is important to a patient or relative when they come into contact with a care setting. Are
we giving them the confidence they need to have a positive experience?”
Two or three people, including a representative of the Trust’s patient experience group, arrive
unannounced at a ward and, using a toolkit with a series of questions and prompts, walk around the area
to get a ‘first impression’.
The visit looks at four areas – is it welcoming, safe, caring and involving, and well organised and calm? Things
to look for include a welcoming reception area, acknowledgement on arrival, contact information, a clean
and uncluttered environment, staff interaction with patients, and patients dressed to protect their dignity.
Dr Dunderdale added: “Ensuring our patients receive excellent quality care is everyone’s responsibility
regardless of the job they do, whether they are a porter or a consultant. The 15 Steps Challenge will provide
us with a valuable snapshot of the care being provided on our wards and departments across the organisation.”
32
PE2 – Recommending the Trust to family and friends
Target: 90% or more of patients to want to recommend the Trust to family and friends.
PE2 – Recommending the Trust to family and friends
Achievement (April 2012 – February 2013): The chart below demonstrates that this target
Target: 90% or more of patients to want to recommend the Trust to family and friends.
has been met, with five consecutive months above the mean set within the SPC chart.
Achievement (April 2012 – February 2013): The chart below demonstrates that this target has been met, with
five consecutive months above the mean set within the SPC chart.
Statistical Process Control (SPC) ‐ Recommending the Trust to family and friends
98
96
94
92
90
88
May‐10
Jun‐10
Jul‐10
Aug‐10
Sep‐10
Oct‐10
Nov‐10
Dec‐10
Jan‐11
Feb‐11
Mar‐11
Apr‐11
May‐11
Jun‐11
Jul‐11
Aug‐11
Sep‐11
Oct‐11
Nov‐11
Dec‐11
Jan‐12
Feb‐12
Mar‐12
Apr‐12
May‐12
Jun‐12
Jul‐12
Aug‐12
Sep‐12
Oct‐12
Nov‐12
Dec‐12
Jan‐13
Feb‐13
Percentage recommending the Trust to friends and family (%) 100
Source:
MenuMenu
card survey,
membership
office
Source:
card survey,
membership
office
Comment:
The
chart
demonstrates
on the
axis of
the
percentage
patients
Comment:
Theabove
above chart
demonstrates
on the vertical
axisvertical
the percentage
patients
who wouldofrecommend
who would
thefamily.
Trust
to horizontal
their friends
family.
On this
theindicator
horizontal
axis the
the Trustrecommend
to their friends and
On the
axis theand
months
over which
has been
months
over iswhich
this in
indicator
has beensince
measured
measured
demonstrated,
this case commencing
May 2010. is demonstrated, in this case
commencing
since
May
2010.
Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality
Account?
Has the
quality indicator been changed during the year from that set in last years
(2011/12)
Quality
Account?
been
nothechange
to this quality
No, there
has been
no change toNo,
this there
quality has
priority
during
2012/13 reporting
period. priority during the
2012/13 reporting period.
Rationale for changing quality priority for 2013/14: The national use of the friends and family question will
replace the local questioning of patients in regard to this question.
Rationale for changing quality priority for
2013/14: The national use of the friends and
family question will replace the local questioning
of patients in regard to this question.
Focus on: Menu Card Survey
The menu card survey is an innovative
way that the Trust seeks patient feedback
regarding a number of patient experience
indicators.
As the name indicates, this survey is on the
back of the lunch time menu card ensuring
it is not far away from patients to ascertain
their feedback.
Directorate of Clinical and Quality Assurance, April 2013
Focus on: Menu Card Survey
The menu card survey is an innovative way
that the Trust seeks patient feedback
regarding a number of patient experience
indicators.
As the name indicates, this survey is on the
back of the lunch time menu card ensuring it
is not far away from patients to ascertain
their feedback.
Page 39 of 97
33
Annual Quality Account 2012/13
PE3 – Trust complaints resolution
Target – 95 per cent of complaints to be closed within the timescale agreed with the
complainant
PE3––Trust
Trustcomplaints
complaints
resolution
PE3
resolution
Achievement
(April
2012
– March
2013):
table
belowagreed
illustrates
broad
achievement
of
Target – 95
perper
cent
of complaints
to be closed
the
timescale
with the
complainant
Target
– 95
cent
of complaints
to within
beThe
closed
within
the
timescale
agreed
with the
this
target
during
the
2012/13
financial
year.
complainant
Achievement (April 2012 – March 2013): The table below illustrates broad achievement of this target during the
2012/13
financial
year.
Jun-11 Jul-11
Aug-11 Sep-11
Oct-11
Nov-11 –
Dec-11
Jan-12 Feb-12
Mar-12
Apr-12
May-12below
Jun-12 Jul-12
Aug-12 Sep-12
Oct-12 Nov-12
Dec-12 Jan-13 Feb-13
Achievement
(April
2012
March
2013):
The
table
illustrates
broad
achievement
of Mar-13
this
target
during
the
2012/13
financial
year.
100% 100% 100% 100% 100% 100% 96% 95% 100% 100% 96% 100% 100% 96% 100% 100% 100% 97% 94% 100% 100% 100%
Jun-11 Jul-11DATIX,
Aug-11 Sep-11
Oct-11set
Nov-11
Dec-11 Jan-12
Mar-12
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13
Source:
live data
reported
oneFeb-12
month
in arrears
100% 100% 100%The
100% Trust’s
100% 100%
96% 95%with
100%commissioners
100% 96% 100% 100%
96% 100%
100% 100%
94% cent
100% 100%
Comment:
contract
stipulates
a target
of 97%
95 per
of
complaints
being
responded
to
within
the
timescales
agreed
with
the
complainant.
The
Source: DATIX, live data set reported one month in arrears
Source: DATIX,
live dataof
setcomplaints
reported one
monthwithin
in arrears
monthly
breakdown
closed
agreed timescales during 2011/12 to date is
Comment:
The
Trust’s
contract
with
commissioners
stipulates a target of 95 per cent of
illustrated
in
the
above
table.
Comment: The Trust’s contract with commissioners stipulates a target of 95 per cent of complaints being
complaints
being
responded
to
within
the
timescales
agreed with the complainant. The
responded to within the timescales agreed with the complainant. The monthly breakdown of complaints closed
monthly
breakdown
of
complaints
closed
within
agreed
timescales
during 2011/12 to date is
within agreed timescales during 2011/12 to date is illustrated in the above table.
illustrated
in thechart
above
table. the number of new complaints received, number closed and
The following
illustrates
The following
chartorillustrates
the currently
number of new
complaints
received,
closed and
‘net open’
or the
the
‘net open’
the total
open
(including
new,number
unresolved
andtheopen
or on
hold
total
currently
open
(including
new,
unresolved
and
open
or
on
hold
complaints).
complaints).
The following chart illustrates the number of new complaints received, number closed and
the ‘net open’ or the total currently
open (including new, unresolved
NLAG complaints resolution January 2010 ‐
present and open or on hold
complaints).
100%
180
160
NLAG complaints resolution January 2010 ‐ present
140
180
120
160
100
140
80
120
60
100
40
80
20
60
400
Ma
Jan‐ Feb Mar Apr
Jun‐ Jul‐ Aug Sep Oct Nov Dec Jan‐ Feb Mar Apr
y‐
10 ‐10 ‐10 ‐10
10 10 ‐10 ‐10 ‐10 ‐10 ‐10 11 ‐11 ‐11 ‐11
10
42 36 51 40 34 47 46 38 27 42 33 18 29 32 27 15
Ma
Jun‐ Jul‐ Aug Sep Oct Nov Dec Jan‐ Feb Mar Apr
y‐
11 11 ‐11 ‐11 ‐11 ‐11 ‐11 12 ‐12 ‐12 ‐12
11
31 37 32 29 25 23 32 20 35 42 47 32
Ma
Jun‐ Jul‐ Aug Sep Oct Nov Dec Jan‐ Feb Mar
y‐
12 12 ‐12 ‐12 ‐12 ‐12 ‐12 13 ‐13 ‐13
12
34 30 43 38 35 52 46 38 48 66 57
24 44 56 35 Ma
34 41 34 46 29 33 34 28 25 26 31 25
Jan‐ Feb Mar Apr
Jun‐ Jul‐ Aug Sep Oct Nov Dec Jan‐ Feb Mar Apr
Net open 10
48 ‐10
40 ‐10
35 ‐10
40 y‐
40 10
46 10
58 ‐10
50 ‐10
48 ‐10
57 ‐10
56 ‐10
46 11
50 ‐11
56 ‐11
52 ‐11
42
10
New
42 36 51 40 34 47 46 38 27 42 33 18 29 32 27 15
35 29 27 25 26 26 25 23 22 17 27 25
Ma
Jun‐ Jul‐ Aug Sep Oct Nov Dec Jan‐ Feb Mar Apr
y‐
38 11
46 11
51 ‐11
55 ‐11
48 ‐11
49 ‐11
65 ‐11
57 12
62 ‐12
79 ‐12
83 ‐12
63
11
31 37 32 29 25 23 32 20 35 42 47 32
34 17 29 19 26 29 60 33 37 33 24
Ma
Jun‐ Jul‐ Aug Sep Oct Nov Dec Jan‐ Feb Mar
y‐
76 12
95 12
90 ‐12
97 ‐12
90 ‐12
112 ‐12
101 ‐12
103 115
147 ‐13
160
13 ‐13
12
34 30 43 38 35 52 46 38 48 66 57
20
0
New
Closed
Closed
24 44 56 35 34 41 34 46 29 33 34 28 25 26 31 25 35 29 27 25 26 26 25 23 22 17 27 25 34 17 29 19 26 29 60 33 37 33 24
Source:
DATIX, clinicaland
andquality
qualityassurance
assurance team
Source: DATIX,
Net open 48clinical
40 35 40 40 46
58 50 48 57 56 46 50team
56 52 42
38 46 51 55 48 49 65 57 62 79 83 63 76 95 90 97 90 112 101 103 115 147 160
Comment: The vertical axis in the above chart illustrates the number of complaints and the horizontal axis
represents
the The
months
forand
which
theindata
available
from, illustrates
commencingthe
in January
2010.
chart illustrates
Source:
DATIX,
clinical
quality
assurance
team
Comment:
vertical
axis
theis above
chart
number
of The
complaints
and that
the
the
number
of
new
complaints
has
increased
leading
to
an
increasing
number
of
net
open
complaints.
horizontal axis represents the months for which the data is available from, commencing in
January
2010.
chart illustrates
thatand
theit appears
numberthat
of anew
complaints
increased
This issue has
beenThe
investigated
in more detail
contributory
factorhas
to the
number of leading
net
Comment:
The
vertical
axis
in open
the above
illustrates
the number
of complaints
and to
the
to
ancomplaints
increasing
number
of net
complaints.
open
is the
increasing
complexity
of the chart
complaints
being received,
and capacity
issues available
horizontal
axis
represents
the
months
for
which
the
data
is
available
from,
commencing
in
respond
to these.
number
of closed complaints
has decreased
inappears
the last months.
This
issue
hasThe
been
investigated
more
and
that ahas
contributory
to
January
2010.
The
chart
illustratesinthat
the detail
number
of itnew
complaints
increasedfactor
leading
the
number
of
net
open
complaints
is
the
increasing
complexity
of
the
complaints
being
A review
of the central
complaints
handling
to
an increasing
number
of net
open arrangements
complaints. has recently been undertaken. Actions underway
received,
and capacity issues available to respond to these. The number of closed
include:
This
issue has
investigated
in more
detail and it appears that a contributory factor to
complaints
has been
decreased
in the last
months.
•• The
appointment
of some
temporary
resource
for threecomplexity
to six monthsof
to help
the backlog
the
number
of net
openadditional
complaints
is the
increasing
the address
complaints
being
A
review
of
the
central
complaints
handling
arrangements
has
recently
been
undertaken.
and
assist
in
addressing
the
increase
received, and capacity issues available to respond to these. The number of closed
Actions underway
include: in the last months.
complaints
has
decreased
•• Changes to
some
of the (current
labour intensive) processes in operation within that area
A
of theofcentral
complaints
handling
arrangements has recently been undertaken.
•• review
Reinforcement
previously
agreed escalation
procedures.
Directorateunderway
of Clinical andinclude:
Quality Assurance, April 2013
Page 40 of 97
Actions
As part of a review of the Trust’s complaints handling arrangements, representatives from the office of the
Parliamentary and Health Service Ombudsman (PHSO) were invited to visit the Trust. This visit was held on
Directorate of Clinical and Quality Assurance, April 2013
34
Page 40 of 97
Wednesday April 10 2013. No concerns were raised during the visit but the information provided by the PHSO
on complaints referred to them about the Trust supports the findings from the internal review and therefore the
actions which are underway to revise and strengthen the Trust’s complaints handling arrangements. A more
detailed report and action plan on the work which is underway will be submitted to the quality and patient
experience committee in May 2013.
This section of the report has focussed specifically on the quantitative data that has been monitored whilst the
Trust has tried to meet this quality indicator. It should be stressed that the Trust uses the qualitative feedback
from complaints in an effort to constantly improve the service provided to local patients and public. Such
information is reported on a quarterly basis within the Trust’s incident and complaints report, received by the
Trust’s governance and assurance committee, a sub-group of the Trust Board.
Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality
Account?
No, there has been no change to this quality priority during the 2012/13 reporting period.
Rationale for changing the quality priority for 2013/14: The Trust will still focus on this important area of
complaints management and responding to complaints. The new indicators for 2013/14 (see page 38) will focus
on reducing the number of re-opened complaints, compliance with agreed timescales for action plans resulting
from a complaint and a reduction in the number of complaints received.
PE4 – Decision making
Target:
95 per cent
of patients to be as involved as much as they wanted to be in
PE4For
– Decision
making
decisions about their care and treatment
Target: For 95 per cent of patients to be as involved as much as they wanted to be in decisions about their care
and treatment
Achievement (April 2012 – February 2013):
The following chart illustrates that
Achievement
(April
2012
–
February
2013):
The
following
chart
illustrates
that performance in this area has
performance in this area has exceeded the 95 per cent target
set.
exceeded the 95 per cent target set.
Question: Were you involved as much as you wanted to be in decisions about your care and treatment?
Percentage (%) 110%
100%
90%
80%
70%
DPoW
Feb‐13
Jan‐13
Dec‐12
Nov‐12
Oct‐12
Sep‐12
Aug‐12
Jul‐12
Jun‐12
May‐12
Apr‐12
Mar‐12
Feb‐12
Jan‐12
Dec‐11
Nov‐11
Oct‐11
Sep‐11
Aug‐11
Jul‐11
Jun‐11
May‐11
60%
May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐ Mar‐ Apr‐ May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐
‐11 11 11 11 11 11 11 11 12 12 12 12 ‐12 12 12 12 12 12 12 12 13 13
80% 77% 91% 97% 96% 97% 96% 98% 94% 95% 99% 95% 100% 95% 94% 96% 99% 99% 100%100% 99% 100%
SGH
86% 87% 95% 73% 88% 100% 96% 97% 99% 98% 100%100% 98% 97% 100%100% 99% 100%100% 98% 99% 99%
GDH
81% 97% 97% 96% 96% 100%100% 96% 100%
100%100% 97% 100%100%100%100%100%100%100%100%100%
Threshold 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%
KEY to abbreviations:
Diana, Princess of Wales Hospital, Grimsby
Scunthorpe General Hospital,
Goole and District Hospital
Source: Information services, Nursing Dashboard v4.0
DPoW: Source: Information services, Nursing Dashboard v4.0
Comment: The above chart illustrates on the vertical axis the percentage
KEY to abbreviations:
DPoW: Diana, Princess of Wales Hospital, GrimsbySGH: of patients who felt they were involved in decision making about their
GDH: SGH: Scunthorpe General Hospital,
care and treatment. ToGDH:
illustrate
this and
dataDistrict
most effectively
Goole
Hospital the vertical axis
in the above chart starts at 60 per cent. The horizontal axis illustrates the
months that this data was available for, commencing in May 2011.
Comment: The above chart illustrates on the vertical axis the percentage of patients who felt
they were involved in decision making about their care and treatment. To illustrate this data
35 axis
most effectively the vertical axis in the above chart starts at 60 per cent. The horizontal
illustrates the months that this data was available for, commencing in May 2011. The above
Annual Quality Account 2012/13
The above data is available from the findings of a monthly nursing audit assessing a random sample of patients
within the Trust as inpatients.
Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality
Account?
No, there has been no change to this quality priority during the 2012/13 reporting period.
Rationale for changing the quality priority for 2013/14: The Trust has consistently performed well with this
indicator, therefore an indicator around staff satisfaction will be incorporated within the 2013/14 quality priorities.
PE5 – Medication side effects
Target:
For staff to tellside
patients
about the medication side effects and what to look for upon
PE5 – Medication
effects
discharge in 95 per cent of cases
Target: For staff to tell patients about the medication side effects and what to look for upon discharge in 95 per
cent of cases
The following chart illustrates that
Achievement (April 2012 – February 2013):
Achievement (April
2012
– February
2013): Thethe
following
chart
illustrates
performance
in this area has
performance
in this
area
has exceeded
95 per
cent
targetthat
set
in most months.
exceeded the 95 per cent target set in most months.
Question: Did a member of staff tell you about medication side effects and what to watch for upon discharge?
120%
Percentage (%) 100%
80%
60%
40%
20%
DPoW
Feb‐13
Jan‐13
Dec‐12
Nov‐12
Oct‐12
Sep‐12
Aug‐12
Jul‐12
Jun‐12
May‐12
Apr‐12
Mar‐12
Feb‐12
Jan‐12
Dec‐11
Nov‐11
Oct‐11
Sep‐11
Aug‐11
Jul‐11
Jun‐11
May‐11
Apr‐11
0%
Apr‐ May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐ Mar Apr‐ May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐
11 ‐11 11 11 11 11 11 11 11 12 12 ‐12 12 ‐12 12 12 12 12 12 12 12 13 13
79% 63% 57% 75% 91% 93% 97% 99% 96% 96% 99% 98% 96% 98% 97% 89%100%99% 98%100%100%99%100%
SGH
84% 65% 76% 67% 77%100%30% 28% 94% 98% 99%100%97% 97% 94%100%99%100%99%100%99%100%100%
GDH
70% 55% 77% 83% 79% 84%100%93% 96%100%
100%89%100%100%100%100%100%95%100%100%100%100%
Threshold 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%
KEY to abbreviations:
Diana, Princess of Wales Hospital, Grimsby
Scunthorpe General Hospital,
Goole and District Hospital
Source: Information services, Nursing Dashboard v4.0
DPoW: Source: Information services, Nursing Dashboard v4.0
Comment: The above chart illustrates on the vertical axis the percentage of
KEY
to abbreviations:
Diana,
of Wales
Hospital,
GrimsbySGH: patients
who felt they wereDPoW:
informed
aboutPrincess
medication
side effects
and what
GDH: SGH:
Scunthorpe
General
Hospital,
to look out for upon discharge.
The
horizontal axis
illustrates
the months
GDH:
Goole
and
District
Hospital
that this data was available for, commencing in April 2011. The above data is
available from the findings of a monthly nursing audit assessing a random sample of patients within the Trust as
inpatients.
Comment:
The
abovebeen
chart
illustrates
vertical
axis
the
percentage
of patients
Has the quality
indicator
changed
duringon
thethe
year
from that
set in
last
year’s (2011/12)
Quality who felt
they
were
informed
about
medication
side
effects
and
what
to
look
out
for
upon discharge.
Account? No, there has been no change to this quality priority during the 2012/13 reporting period.
The horizontal axis illustrates the months that this data was available for, commencing in
Rationale for changing the quality priority for 2013/14: The Trust has consistently performed well with this
April 2011. The above data is available from the findings of a monthly nursing audit
indicator, therefore this indicator will not be monitored within the 2013/14 quality priorities.
assessing a random sample of patients within the Trust as inpatients.
Has the quality indicator been changed during the year from that set in last years
(2011/12) Quality Account? No, there has been no change to this quality priority during the
2012/13 reporting period.
36
Rationale for changing the quality priority for 2013/14: The Trust has consistently
PE6 – Nursing care indicator
Target: For the overall nursing care indicator to be 95 per cent.
PE6 – Nursing care indicator
following chart illustrates that this indicator
Achievement
(April
2012
– February
Target: For the
overall
nursing
care indicator2013):
to be 95The
per cent.
more recently has on the whole been achieved. This information is monitored within the
Achievement
(Aprilby
2012
– February
2013):
chartwill
illustrates
that this indicator
more recently with
has
nursing
dashboard
matrons
and
so The
anyfollowing
concerns
be identified
and addressed
on the whole been achieved. This information is monitored within the nursing dashboard by matrons and so any
individual nursing areas.
concerns will be identified and addressed with individual nursing areas.
Nursing care indicators ‐ overall score
100
Percentage (%) 95
90
85
80
75
Feb‐13
Jan‐13
Dec‐12
Nov‐12
Oct‐12
Sep‐12
Aug‐12
Jul‐12
Jun‐12
May‐12
Apr‐12
Mar‐12
Feb‐12
Jan‐12
Dec‐11
Nov‐11
Oct‐11
Sep‐11
Aug‐11
Jul‐11
Jun‐11
May‐11
Apr‐11
70
Apr‐ May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐ Mar‐ Apr‐ May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐
11 ‐11 11 11 11 11 11 11 11 12 12 12 12 ‐12 12 12 12 12 12 12 12 13 13
DPoW 86 83 82 87 86 87 87 89 94 95 94 91 89 93 93 90 95 96 96 98 98 96 97
SGH
88
86
87
87
86
82
83
80
94
95
GDH
86
83
84
86
86
86
89
90
94
95
96
91
91
92
87
95
94
95
98
98
97
93
94
92
91
91
92
94
98
95
97
98
97
98
98
KEY to abbreviations:
Diana, Princess of Wales Hospital, Grimsby
Scunthorpe General Hospital,
Goole and District Hospital
Source: Information Services, Nursing Dashboard v4.0
DPoW: Source: Information Services, Nursing Dashboard v4.0
Comment: The above chart illustrates on the vertical axis the percentage
KEY to
abbreviations:
DPoW:care
Diana,
Princess
of Wales
Hospital,
compliance
with the nursing
indicators
overall
score whilst
the GrimsbySGH: SGH:
General
GDH: horizontal axis illustrates
the Scunthorpe
months for which
thisHospital,
data is available
GDH:
Goole
andpresentation
District Hospital
starting in April 2011. For
most
effective
of these results the
above vertical axis starts at 70 per cent.
Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality
Comment:
Account?The above chart illustrates on the vertical axis the percentage compliance with
the nursing care indicators overall score whilst the horizontal axis illustrates the months for
there has been no change to this quality priority during the 2012/13 reporting period.
whichNo,this
data is available starting in April 2011. For most effective presentation of these
results
the above
verticalthe
axis
starts
at 70forper
cent.No changes, this will be monitored during 2013/14.
Rationale
for changing
quality
priority
2013/14:
Has the quality indicator been changed during the year from that set in last years
(2011/12) Quality Account? No, there has been no change to this quality priority during the
2012/13 reporting period.
Rationale for changing the quality priority for 2013/14: No changes, this will be monitored
during 2013/14.
Directorate of Clinical and Quality Assurance, April 2013
Page 44 of 97
37
Annual Quality Account 2012/13
2.2: Quality Priorities for 2013/14
Rationale for quality priorities:
The quality priorities for 2013/14 have been identified as a result of the Trust’s concentrated monitoring of
the previous year’s priorities and are linked to its continuing focus on ensuring patients and service users
are provided with safe and effective care and treatment. A number of the new indicators relate to the Trust’s
continued attention on identifying and caring appropriately for deteriorating patients. Dementia, falls and
pressure ulcers remain as key priority areas along with a renewed assessment and targeting to increase harm
free care delivered. Patient experience remains an important area and as such has been focussed on in the
form of patient participation in the national friends and family test and a focus on the reduction in the number
of complaints. A new indicator for 2013/14 focusses on the Trust’s work with its staff and will outline and track
progress of work underway to help improve staff experience and the organisation’s culture.
How agreed:
The priorities for 2013/14 have been agreed by the Trust Board and by the quality and patient experience
committee. They have been identified via a number of mechanisms including the following:••
Discussions with the governors at the service quality monitoring group
••
Discussions with the commissioners
••
The findings from the national surveys (outpatient and inpatient)
••
The findings from the staff survey
••
Findings from the numerous patient satisfactions surveys that are undertaken by the Trust
••
The results that are published within our nursing dashboard
••
The data provided by our clinical systems where we are identified as being an outlier
••
Information from the Care Quality Commission quality and risk profile
••
Information from incidents and complaints
••
Comments received from local LINKS as a result of discussions around last year’s quality account.
Taking into account the wider public views:
The quality indicators are agreed following discussions with governors who represent the interests of their
constituents following their election to this role from public members of the Trust. The findings from the inpatient
and outpatient surveys are also considered when developing these proposed indicators to take into account the
views of the wider public. Feedback and comments from the local overview and scrutiny committees, made up of
elected councillors who represent their constituents, is also taken into account when formulating the proposed
new quality indicators.
How progress will be monitored and measured:
Progress against these indicators will be reported monthly using the monthly quality report. The following
indicators in most cases include improvement targets to allow for ongoing measurement. A selection of methods
will be employed to measure this area including Statistical Process Control (SPC) charts, tables and graphs. The
quality and patient experience committee (QPEC) and the Board will receive this report. A governor is a member
of the quality and patient experience committee and will report back to the other governors. This report is also
shared with the Trust’s commissioners.
38
2013/14 Quality priorities:
Clinical effectiveness
CE1
Mortality – the detail of this indicator is being discussed at the mortality performance committee and a
recommendation will be made to the Board at a future meeting.
CE2
The provider to provide details of the number of patients who should have had a NEWS score, the number
of patient who did have a NEWS score, number of patients whose NEWS score was completed correctly and
number of patients who were actioned appropriately.
CE3
Dementia –
CE3.1 90 per cent of patients aged 75 and over admitted as an emergency to be asked the dementia case
finding question.
CE3.2 90 per cent of the above patients scoring positive on the case finding question to have a further risk
assessment.
CE3.3 90 per cent of the patients identified as requiring referral following the risk assessment to be referred in
line with local pathway.
CE4
Evidence based practice – increase compliance with NICE guidance with 90 per cent compliance achieved by
the end of March 2014.
Patient safety
PS1
MRSA – limit of 0 has been set for 2013/14.
PS2
Clostridium difficile – limit of 30 has been set for 2013/14.
PS3
Safety thermometer – increase in harm free care (acute) – target to be agreed once quarter four baseline has
been received.
PS4
Safety thermometer – increase in harm free care (community) – target to be agreed once quarter 4 baseline has
been received.
PS5
PS6
Falls – reduction in avoidable harm – target to be agreed once quarter four baseline has been received.
Committee to still receive numbers of avoidable falls.
Pressure ulcers – reduction in avoidable harm – target to be agreed once quarter four baseline has been
received. Committee to still receive number of avoidable pressure ulcers.
Patient experience
PE1
Friends and family test – to have a response rate that achieves a response rate in the top 50 per cent which also
improves on the quarter one response rate.
PE2
Complaints – a reduction in the number of re-opened complaints – target to be achieved once Quarter 4
baseline has been received
PE3
Complaints – 90 per cent of action plans following a complaint to be implemented within the agreed
timescales.
PE4
A 10 per cent reduction in the number of complaints received by the Trust by the end March 2014.
PE5
For the overall nursing care indicator to be 95 per cent.
PE6
To implement a cultural barometer within the Trust and obtain a baseline reading from which an improvement
trajectory can be set. Quarterly updates will be provided to the committee.
39
Annual Quality Account 2012/13
2.3 Statements of assurance from the Board
2.3a Information on the review of services
During 2012/13 Northern Lincolnshire and Goole Hospitals NHS Foundation Trust provided and/or sub-contracted
24 relevant health services. The Trust has reviewed all the data available to them on the quality of care in 24 of
these relevant health services.
The income generated by the NHS services reviewed in 2012/13 represents 100 per cent of the total income
generated from the provision of relevant health services by the Trust for 2012/13.
The data reviewed aims to cover the three dimensions of quality – patient safety, clinical effectiveness and patient
experience – and indicate where the amount of data available for review has impeded this objective.
2.3b Information on participation in clinical audits and national confidential enquiries
During 2012/13, 38 national clinical audits and three national confidential enquires covered relevant health
services that Northern Lincolnshire and Goole Hospitals NHS Foundation Trust provides.
During 2012/13 the Trust participated in 100 per cent national clinical audits and 100 per cent national
confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to
participate in.
The national clinical audits and national confidential enquiries that the Trust was participated in during 2012/13
are as follows.
The national clinical audits and national confidential enquiries that the Trust participated in, and for which data
collection was completed during 2012/13, 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 teams of that audit or enquiry.
40
National clinical audits
National clinical audit title
Eligible
for NLAG
NLAG
participated
Number
of cases
submitted
% of number
required
Action
planning
Acute care
Adult community acquired
pneumonia
Yes
Yes
Project still
ongoing
Project still
ongoing
N/A
Yes
Yes
871
100%
No
Yes
Yes
24
100%
Awaiting
report
No
N/A
N/A
N/A
N/A
Hip, knee and ankle replacements
(National Joint Registry)
Yes
Yes
568
100%
Awaiting
report
Adult Non-Invasive Ventilation
(British Thoracic Society)
Yes
Yes
project still
ongoing
project still
ongoing
N/A
Yes
Yes
100
100%
Yes
Yes
Yes
259
100%
Yes
(British Thoracic Society)
Adult critical care
(ICNARC CMPD)
Emergency use of oxygen
(British Thoracic Society)
Medical and Surgical programme:
National Confidential Enquiry into
Patient
Outcome and Death (NCEPOD)
Bariatric Surgery
(also known as Medical and
Surgical Clinical Outcome
Review Programme, or Patient
Outcome and Death)
*also confidential enquiry
Renal Colic
(College of Emergency Medicine)
Severe trauma (Trauma Audit and
Research Network)
Blood and transplant
Intra-thoracic transplantation
(NHSBT UK Transplant Registry)
National Comparative
Audit of Blood Transfusion
- programme includes the
following audits, which were
previously listed separately in
QA:
No
N/A
N/A
N/A
N/A
Yes
Yes
100
100%
Yes
Yes
Yes
256
100%
Awaiting
report
a) O neg blood use
b) Medical use of blood
c) Bedside transfusion
d) Platelet use
Potential donor audit (NHS
Blood and Transplant)
41
Annual Quality Account 2012/13
National clinical audit title
Eligible
for NLAG
NLAG
participated
Number
of cases
submitted
% of number
required
Action
planning
Acute care
Cancer
Lung cancer (National Lung
Cancer Audit)
Yes
Yes
313
100%
Awaiting
report
Bowel cancer (National Bowel
Cancer Audit Programme)
Yes
Yes
204
100%
Yes
Head and neck cancer
(DAHNO)
Yes
Yes
52
100%
Yes
Oesophago-gastric cancer
(National O-G Cancer Audit)
Yes
Yes
91
100%
Yes
Heart
Acute Myocardial Infarction and
other ACS (MINAP)
Yes
Yes
248
100%
Awaiting
report
Adult Cardiac Surgery Audit (ACS)
No
N/A
N/A
N/A
N/A
Cardiac arrhythmia (Cardiac
Rhythm Management Audit)
Yes
Yes
397
100%
Yes
Paediatric cardiac surgery (NICOR
Congenital Heart Disease Audit)
No
N/A
N/A
N/A
N/A
Coronary angioplasty (NICOR
Adult cardiac interventions audit)*
Yes
Yes
311
100%
Awaiting
report
Heart failure (Heart Failure Audit)
Yes
Yes
201
100%
Awaiting
report
Yes
Yes
Project still
ongoing
Project still
ongoing
N/A
National Vascular Registry
(elements include CIA, peripheral
vascular surgery, VSGBI Vascular
Surgery Database, NVD)
No
N/A
N/A
N/A
N/A
Pulmonary hypertension
(Pulmonary Hypertension Audit)
No
N/A
N/A
N/A
N/A
Cardiac arrest
(National Cardiac Arrest Audit)
42
National clinical audit title
Eligible
for NLAG
NLAG
participated
Number
of cases
submitted
% of number
required
Action
planning
Acute care
Long term conditions
Adult asthma
(British Thoracic Society)
Yes
Yes
30
100%
Awaiting
report
Bronchiectasis
(British Thoracic Society)
Yes
Yes
14
100%
Awaiting
report
Diabetes (Adult) ND(A), includes
National Diabetes Inpatient Audit
(NADIA)
Yes
Yes
3218
100%
Awaiting
report
102
100%
Yes
Yes
Yes
201
100%
Awaiting
report
Yes
Yes
Project still
ongoing
Project still
ongoing
N/A
National Review of Asthma
Deaths (NRAD)
Yes
Yes
Project still
ongoing
Project still
ongoing
N/A
Pain Database (National Pain
Audit)
Yes
Yes
90
100%
Awaiting
report
Renal replacement therapy (Renal
Registry)
No
N/A
N/A
N/A
N/A
Renal transplantation (NHSBT UK
Transplant Registry)
No
N/A
N/A
N/A
N/A
Diabetes (RCPH National
Paediatric Diabetes Audit)
Inflammatory bowel disease (IBD)
Includes: Paediatric Inflammatory
Bowel Disease Services
Mental health
Mental Health programme:
National Confidential Inquiry into
Suicide and Homicide for people
with Mental Illness (NCISH)
(also known as suicide and
homicide in mental health, or
Mental Health Clinical Outcome
Review Programme)
National audit of psychological
therapies (NAPT)
Prescribing Observatory for
Mental Health (POMH)
(Prescribing in mental health
services)
No
N/A
N/A
N/A
N/A
No
N/A
N/A
N/A
N/A
No
N/A
N/A
N/A
N/A
43
Annual Quality Account 2012/13
National clinical audit title
Eligible
for NLAG
NLAG
participated
Number
of cases
submitted
% of number
required
Action
planning
Acute care
Older people
Carotid interventions audit
(CIA)
No
N/A
N/A
N/A
N/A
Fractured Neck of Femur
(College of Emergency
Medicine)
Yes
Yes
50
100%
Yes
Hip fracture (National Hip
Fracture Database)
Yes
Yes
506
100%
Yes
National Audit of Dementia
Yes
Yes
80
100%
Yes
Parkinson's disease (National
Parkinson's Audit)
Yes
Yes
20
100%
Awaiting
report
269
100%
SINAP
changed to
SSNAP
Project still
ongoing
Project still
ongoing
Project still
ongoing
737
70%
Yes
Sentinel Stroke
National Audit Programme
(SSNAP) - programme
combines the following audits,
which were previously listed
separately in QA:
Yes
Yes
a) Sentinel stroke audit
b) Stroke improvement
national audit project
Other
Elective surgery (National
PROMs Programme)
44
Yes
Yes
National clinical audit title
Eligible
for NLAG
NLAG
participated
Number
of cases
submitted
% of number
required
Action
planning
Acute care
Women and Children’s
Child Health Programme RCPCH
Yes
Yes
Project still
ongoing
Project still
ongoing
N/A
Epilepsy 12 – Childhood (RCPH
National Audit)
Yes
Yes
Project still
ongoing
Project still
ongoing
N/A
Yes
Yes
23
100%
Yes
Neonatal intensive and special
care (NNAP)
Yes
Yes
1521
100%
Awaiting
report
Paediatric asthma (British
Thoracic Society)
Yes
Yes
16
100%
Awaiting
report
Yes
Yes
100
100%
Yes
Paediatric intensive care (PICANet)
No
N/A
N/A
N/A
N/A
Paediatric pneumonia (British
Thoracic Society)
Yes
Yes
14
100%
Awaiting
report
Total:
51
Eligible
38
Maternal, infant and new-born
programme (MBRRACE-UK)*
(Also known as Maternal, Newborn and Infant Clinical Outcome
Review Programme)
*This programme was previously
also listed as Perinatal Mortality
(in 2010/11, 2011/12 quality
accounts)
Feverish Illness in Children/
Paediatric Fever
(College of Emergency)
45
Annual Quality Account 2012/13
National Confidential Enquiries
Eligible
for NLAG
NLAG
participated
Number
of cases
submitted
% of number
required
Action
planning
Subarachnoid Haemorrhage
Yes
Yes
2
67%
Awaiting
results
Alcohol Related Liver Disease
Yes
Yes
2
33%
Awaiting
results
Cardiac Arrest Procedures
Yes
Yes
4
67%
Ongoing
Bariatric Surgery
No
N/A
N/A
N/A
N/A
Confidential Enquiry
Total:
4
The reports of four national clinical audits were reviewed by the provider in 2012/13 and the Trust intends to take
the following actions to improve the quality of healthcare provided:
Thematic analysis:
Based on the action plans from these projects, the following themes were identified from the national audits
undertaken and reported back within the Trust:
Increased information to patients/carers
••
Development of an information leaflet for parents/careers regarding pyrexia in children
••
Improved patient information to be made available in the outpatients department.
Increased awareness and education of staff
••
Increased awareness and education for all staff on recording pain score
••
Re-education regarding the use of the NICE traffic light system
••
Continuing education of AMU and other wards to identify stroke cases, and once identified to inform the
stroke unit
••
Increase awareness to all staff on recording pain score and the importance of re-evaluating all patients’ pain
score and to ensure these are adequately documented within the emergency record.
Identified need for further evaluation/patient surveys
••
To develop a questionnaire on patient experience and an annual report based on the results.
Changes to service
••
Thrombolysis to be offered from April/May 2013 24 hours a day, seven days a week
••
Seven day ward rounds to be provided using telemedicine
••
Increase the number of nurses on the stroke unit (Scunthorpe).
Collaborative/MDT working to be improved/discussed
••
Invite ambulance Trust representatives and a patient representative to be part of the stroke steering group
••
Invite social services representative to be part of the stroke steering group
••
A local method of extracting and reporting site specific data had been set up to be presented at general
surgery audit meetings in order to increase knowledge of annual performance prior to publication of reports.
46
The reports of 19 local clinical audits were reviewed by the provider in 2012/13 and the Trust intends to take the
following actions to improve the quality of healthcare provided:
Based on the action plans from these projects, the following themes were identified from these local audits
undertaken and reported back within the Trust:
Increased information to patients/carers
••
Workshops and advertising to improve awareness relating to ovarian cancer in the community.
Increased awareness and education of staff
••
Increased education by including discharge letters as part of the junior doctor induction programme by the
quality and audit team, along with documentation and consent specific educational updates
••
General surgery business manager to use two rolling half-day audit meetings to hold a theatre safety event
with case discussions and “how to” and “how not to” complete the WHO checklist videos as on the NPSA
website
••
To present cases (near misses and incidents from this Trust and any other possible/publicised cases) at
mortality and morbidity rolling half-day meetings chaired by Dr Liz Scott (medical director) to highlight
importance in completing and delivering the checklist in the correct manner
••
To play video from NPSA website at mortality and morbidity meetings in August (SGH) and October (DPOW)
following case presentations showing how the WHO checklist should be delivered and completed
••
The audit department liaised with general surgeons at both sites in order to set up a more robust process
where attempts are made to present and discuss all general surgery mortality cases and morbidity cases at
audit meetings in an attempt to identify learning
••
Pocket sized aide memoire’s to be designed to allow all clinicians to refer to the CNST standards on a daily basis
to act as a reminder when documenting in the maternity records thus helping active risk management
••
Best practice boards CNST to be developed and altered monthly according to the ‘hot’ topic either highlighted
from the audit results or in clinical practice
••
Stickers to be used in the maternity records for a number of conditions ie multiple pregnancy and birth to
ensure clinicians remember to clearly document a management plan in the records
••
Laminated notice to be placed on all CTG machines within maternity to remind clinicians of best practice
and to raise awareness of what should be recorded on the CTG eg fresh eyes review or any opinion sought by
medical staff,
••
Template to be designed to use at the six week post-operative review appointment to aid communication with
the patient and provide evidence of discussion in the maternity records
••
Algorithm/poster to be displayed in antenatal clinic to raise awareness of CNST requirements and best practice
••
Workshops to be provided to clinicians to raise awareness of the guidelines in treating obesity in pregnancy
••
Preferred place of care added to the Liverpool Care Pathway in order to prompt discussion and aid
documentation
••
To be rolled out to community services for inclusion in their Liverpool Care Pathway documentation in order to
ensure consistency
••
Information leaflet/management of condition/out of hours/holiday cover information given to patients is
updated when appropriate and provided and reinforced continuously to patients, where appropriate
••
Re-iterate to all staff the use of correct infection control procedures and the use of hand-gel
••
New electronic template for the family assessment agreed and to be added to SystmOne
••
Ensure correct level of detail is completed to ensure all ‘other’ health professionals reading the record are
assured of the level of assessment completed
••
Revisit and reinforce the principles of the significant event sheet in order to ensure completion.
47
Annual Quality Account 2012/13
Identified need for further evaluation/patient surveys
••
Following changes and evidence of education, re-audit to re-assess compliance
••
Following a review of data from the information team as above it was identified that “acute kidney injury” or
“acute renal failure” was one of the areas contributing to mortality within this group. The audit department
used research and national audits such as NCEPOD acute kidney injury: adding insult to injury, and NHS kidney
care to put together a care bundle in order to assess the quality of care for these patients. Following this and a
pilot of five cases, three consultants reviewed the care bundle and felt that only one standard should be added
to the care bundle. This care bundle was then used to assess the quality of care for the patients that fell in to
the acute kidney injury and acute renal failure primary diagnosis area, following review and reporting this care
bundle can again be put in to a local guideline for use throughout the trust.
••
Supervisors and managers to audit two sets of case notes per month using the electronic audit tool to assess
documentation relating to antennal, intrapartum and postnatal care. Supervisors to feed back to the individual
midwife/doctor where documentation has been poor and feed. Best practice or good documentation to be
provided with a certificate
••
Once electronic capabilities established and implemented carry out re-audit in order to compare results
(approximately six months following implementation)
••
Carry out a snapshot audit on a regular basis to ensure continued improvement and highlight any areas for
action.
Changes to service
••
Amend the electronic discharge letter template to include specific, mandatory questions (duration, INR range,
indication etc.) and the prescribing of anti-coagulants
••
Amend the electronic discharge letter template to have separate lists for new, continuing and discontinued
medication
••
Move current pain charts location to ensure it is in the vicinity of the drug chart to improve ergonomics and
recording of effectiveness of analgesia
••
Pain assessment to be discussed on a compulsory basis at ALERT course
••
Acute pain nurses to liaise and have uniform approach to teaching on the use of the pain chart
••
To make several physical amendments to the checklist and add signature boxes to the checklist for
anaesthetist, ODP, circulating practitioner and surgeon to aid compliance and recording of key information
••
Abortion certificates to be stored securely in the health records (not elsewhere in the department)
••
Referral information to be date stamped upon receipt from the general practitioners (GP)
••
Where the GP has completed signature one, this form should then be utilised by hospital staff with signature
two being completed on that same certificate
••
Handover tools to be devised based on SBAR to aid verbal handover at time of shift changeover
••
To devise a DNA form to be placed in the maternity notes to evidence that the women have been contacted
following a missed appointment in the antenatal period
••
To ensure privacy is maintained when carrying out immunisations in schools, wherever possible, by ensuring
all windows and windows within doors are covered – immunisation team to take paper roll and tape to all
sessions and cover windows where required
••
In order to ensure privacy is maintained and behaviour is not compromised when children are waiting for their
immunisations re-look at the waiting area and discuss with the school the possibility of a different area for
children waiting to receive their immunisations. Discuss the number of children being released from lesson
and request that no more than 10 children at a time are released and waiting
••
Discuss the possibility of recording significant events directly into the patient’s record in SystmOne ie via read-codes
••
If the recording of significant events in SystmOne is possible, roll out implementation to all teams
••
Devise and distribute a ‘NILL’ report form for use when a full report is not required.
48
2.3c Information on participation in clinical research
The total number of patients receiving relevant health services provided or sub-contracted by Northern
Lincolnshire and Goole Hospitals NHS Foundation Trust in 2012/13 that were recruited during that period to
participate in research approved by a research ethics committee is not known as this data is not collected.
However, those patients recruited to NIHR adopted research studies was 577.
NB: It should be noted that all studies opened within the Trust are subject to rigorous governance checks before
they are opened within the Trust which includes submission to a research ethics committee where required.
Thus additional patients will be involved in research studies where by the actual patient accrual is not reported
through research and development as a core expectation of the Trust at this time ie in house/academic studies
that are not NIHR adopted.
The Trust takes part in clinical research, this is because it believes that research is important because it helps to
improve healthcare by finding out which treatments work best for patients. It also gives patients the opportunity
to access novel and innovative treatments and therapies. Within the department we have adopted the NIHR
strapline of ‘Today’s research is Tomorrow’s Treatment’ which captures the essence of what our service is about.
The research and development department (R&D)offers a central corporate function within the Trust and takes
an organisational-level lead in ensuring that research is conducted and managed to high scientific, ethical and
financial standards. The R&D function is delivered from two offices based at the Scunthorpe and Grimsby sites
and is led and managed by the head of research and professional development supported by a team of 10
research nurses, three data coordinators and a projects coordinator.
Within the research and development department, our aims are
••
To increase the number of research studies open within the Trust, including industry studies that may also
generate income. Such income is then re-invested within the Trust in the areas of further research and
professional development
••
To increase the number of patients recruited to studies within the Trust thus increasing the opportunities for
patients to access new and cutting edge treatments which may not be offered through routine care delivery
••
To improve the time that it takes to open a research study within the Trust.
The R&D department are currently supporting a range of research projects. These include,
••
National Institute of Health Research (NIHR) portfolio adopted research
••
Non-portfolio research
••
Commercially sponsored studies
••
Academic and in-House research studies.
As at September 2012, there were 99 studies open in the Trust.
How the research and development team help to deliver research
The team of nurses, data coordinators help to deliver research within our Trust in the following ways:
••
By identifying patients suitable for research studies – involvement is entirely voluntary and never undertaken
without formal written consent from the volunteers
••
By supporting the investigators in delivering the research studies on a day-by-day basis, including seeing
patients in clinics and at home where required
••
Following-up of the patients involved in the studies once the actual treatment stage has been completed – this
can be for a number of years in some studies
••
Collecting the data that contributes to the results of studies. This then goes onto changing practices and
treatments in the future.
49
Annual Quality Account 2012/13
We currently have research projects open in the following areas:
Oncology
Diabetes
Dermatology
Paediatrics
Haematology
Gastrointestinal
Rheumatology
Nursing
Stroke
Obstetrics
ITU
Management
Cardiology
Gynaecology
Surgery
Neurology
The R&D department is dedicated to supporting and furthering research, development and innovation within the
Trust. The department provides assistance and guidance on how to:
••
Check whether projects are research, service evaluation or audit
••
Help and advice on protocol development, study design, data management and analysis
••
Assist in the set up a study
••
Coordinate a submission to the research ethics committee (REC) and where necessary Medicines and
Healthcare Products Regulatory Agency (MHRA) to facilitate approvals
••
Undertake the necessary NHS Trust approval process on behalf of Northern Lincolnshire and Goole Hospitals
NHS Foundation Trust.
We can also provide information about training courses offered by other training providers in the field of health
service research, local and national funding opportunities and research and development publications.
2.3d Information on the Trust’s use of the CQUIN framework
A proportion of the Trust’s income in 2012/13 was conditional upon achieving quality improvement and
innovation goals agreed between the Trust and 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. Further details of the agreed goals for 2012/13 and for the following 12 month
period are available online at:
http://www.monitor-nhsft.gov.uk/sites/all/modules/fckeditor/plugins/ktbrowser/_openTKFile.php?id=3275
The amount of income in 2012/13 which was conditional upon achieving quality improvement and innovation
goals was £6.2 million.
The areas of care which were included within the CQUIN scheme for 2012/13 included the following:
••
VTE risk assessment
••
Patient experience
••
Dementia
••
NHS Safety Thermometer – utilised in the hospital and in the community
••
End of Life Care in the hospital
••
Improving hospital discharge
••
Deteriorating patient.
The monetary total value for 2011/12 CQUIN indicators that the Trust received payment for was £3.6 million.
2.3e Information on never events
The Trust reported three never events during 2012/13. Two related to the never event category ‘retained foreign
object post-operation’. In one case this was following an abdominal surgery and in the other case a retained swab
was present following a vaginal delivery. The third never event was in the ‘wrong operation’ category and was an
incorrect ophthalmic operation.
50
2.3f Information relating to the Trust’s registration with the Care
Quality Commission
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust is required to register with the Care Quality
Commission and its current registration status is unconditional.
The Care Quality Commission has not taken enforcement action against the Trust during 2012/13.
The Trust has not participated in any special reviews or investigations by the Care Quality Commission during the
reporting period.
2.3g Information on quality of data
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust submitted records during 2012/13 to the
secondary uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data.
••
••
The percentage of records in the published data:
••
Which included the patient's valid NHS Number was:
••
99.1 per cent for admitted patient care
••
99.3 per cent for outpatient care 94.9 per cent for accident and emergency care.
Which included the patient's valid General Practitioner Registration Code was:
••
99.9 per cent for admitted patient care
••
99.9 per cent for outpatient care
••
99.7 per cent for accident and emergency care.
2.3h Information on information governance
The Trust’s information governance assessment report overall score for 2012/13 was 68 per cent and was
satisfactory.
2.3i Information on payment by results clinical coding audit
The Trust was subject to the Payment by Results clinical coding audit during the reporting period by the Audit
Commission. However, at the time of writing this account the Trust has only just received in draft the findings
from this. At present some work is ongoing with the Audit Commission to ensure the report is factually correct.
Once complete a final report will be issued. At this time therefore the error rates reported in the latest published
audit for that period for diagnoses and treatment coding (clinical coding) are not able to be reported.
As a result of having not received the final report, Northern Lincolnshire and Goole Hospitals NHS Foundation
Trust cannot outline what actions it will be taking to improve data quality.
2.3j Trust performance against a core set of indicators
From 2012/13 the Department of Health has requested all NHS organisations to report against a core set of
indicators for at least the last two reporting periods (last two years), using a standardised statement set out in
the NHS (Quality Accounts) Amendment Regulations 2012. Some of those indicators were not relevant to the
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust; therefore the following indicators reported on
are only those relevant to the Trust.
51
Annual Quality Account 2012/13
The information has been made available from the Health and Social Care Information Centre, and so where
possible a comparison has been made of the numbers, percentages, values, scores or rates of each of the
Foundation Trust’s indicators with:
a).
The national average for the same
b).
Those NHS Trusts and the NHS Foundation Trusts with the highest and lowest of the same.
This information has been presented as follows in table format.
2.3k: Summary Hospital-Level Mortality Indicator (SHMI)
The data made available to the Trust by the Health and Social Care Information Centre with regard to:
a).
The value and banding of the summary hospital-level mortality indicator (SHMI) for the Trust for the
reporting period:
Trust
value
Trust
banding
National
average
National
best
National
worst
April 2010 – March 2011
1.14
1
1.00
0.67
1.21
January 2012
July 2010 – June 2011
1.12
2
1.00
0.67
1.21
April 2012
October 2010 – September 2011
1.16
1
1.00
0.67
1.23
July 2012
January 2011 – December 2011
1.16
1
1.00
0.69
1.25
October 2012
April 2011 – March 2012
1.17
1
1.00
0.71
1.25
January 2013
July 2011 – June 2012
1.18
1
1.00
0.71
1.26
April 2013
October 2011 – September 2012
1.15
1
1.00
0.68
1.21
Publication
date
Sample time frame
October 2011
Source: NHS information centre
Comment: The above table illustrates the Trust’s performance against the Summary Hospital Mortality Indicator
(SHMI). As referred to earlier in this report, the Trust monitors performance against a number of mortality
indicators including the Risk Adjusted Mortality Index (RAMI) and the SHMI. Both are Standardised Mortality
Ratios (SMR) but both are calculated using different methodologies thus preventing like for like comparison. One
key difference between the two indicators is SHMI indicators inclusion of deaths within the community (within
30 days of hospital discharge), whilst the RAMI indicator focusses solely on in hospital mortality. Due to the
SHMIs inclusion of community mortality, it requires additional data to that made available by the Trust through
routine hospital coding. This indicators reliance on other data sources results in a delayed reporting of the data,
as illustrated by the most recent SHMI publication release in April 2013 assessing a time frame of October 2011 –
September 2012. This delay in reporting makes it difficult for the Trust to continuously in real time monitor this area
using SHMI alone, hence why the Trust uses this in collaboration with other mortality indices such as the RAMI.
The table illustrates the Trust reported performance with SHMI and for each quarterly release outlines the
average UK performance, the national best and worst. The Trust banding is defined as follows from guidance from
The Information Centre:
Banding number using the 95% control limit derived from a random effects model applying a 10 per cent trim for
over dispersion with:
•
1 – higher than expected
•
2 – as expected
•
3 – lower than expected.
b).
The percentage of patient deaths with palliative care coded at either diagnosis or speciality level for the
Trust for the reporting period.
52
Publication
date
% with palliative care
at either diagnosis or
specialty level
National average
National highest
National lowest
October 2011
5.9%
16.7%
38.9%
0.1%
January 2012
6.6%
16.1%
40%
0.1%
April 2012
8.2%
16.6%
41.6%
0%
July 2012
10.6%
17.3%
41.7%
0%
October 2012
12.5%
18.1%
44.2%
0%
January 2013
13.6%
18.6%
46.3%
0.3%
April 2013
13.9%
19.2%
43.3%
0.2%
Source: NHS information centre
Comment: The above table illustrates the percentage of patients with a palliative care code used at either
diagnosis or specialty level. Palliative care coding is a group of codes used by hospital level coding teams to
reflect palliative care treatment of a patient during their hospital stay. The Statistically calculated Standardised
Mortality Ratios (SMR) of which the Risk Adjusted Mortality Index (RAMI) and the Summary Hospital Level
Mortality Indicator (SHMI) are both a part of all differ in how patients with palliative care codes feature within the
indicators. The RAMI indicator excludes all patients who have a palliative care code, however the Trust is required
to meet strict rules that govern the use of such codes to only those patients appropriately seen and managed by
a specialist palliative care team. The SHMI indicator on the other hand does not exclude this group of patients,
rather they are included and the appropriate risk factor for each is statistically determined according to the
model. As palliative care coding is a key mortality indicator, the SHMI on publication each quarter include the
above breakdown of data for Trusts to see the proportion of palliative care codes being used versus the national
average.
The above table therefore illustrates the percentage of patients each quarter where palliative care codes have
been used in either the patient’s specific diagnosis or at the specialty team level of those caring for the patient.
It is noticeable during successive quarters of a gradual increase in the level of palliative care codes being used,
this demonstrates some of the work undertaken within the Trust to ensure appropriate palliative care support
is provided as and when needed and improving recording systems to ensure when the palliative care specialist
team are involved this is accurately captured within the hospital coding.
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust considers that this data is as described for the
following reasons:
••
The Summary Hospital Mortality Indicator (SHMI) is published on a quarterly basis, however as a result of this
indicator including community mortality information as well as in-hospital deaths it relies on data from the
Office for National Statistics. This incurs a delay resulting in a significant lag in reporting Trust performance. At
present the most complete data available to the Trust, at the time of writing this report, was for the period of
October 2011 – September 2012. A number of improvements have been made in the recording and capture
of key information that is drawn on by SHMI during the last two quarters of 2012. At present, due to the
indicator’s time lag, these improvements have not yet shown through in the data
••
The Trust has been actively working with this mortality indicator alongside other indicators used internally to
monitor performance and as a result a number of improvement projects are currently running assessing data
quality, which has a big impact on how these indicators are calculated as well as clinical projects
••
The Trust recognises the need to improve palliative care provision and is in active discussion with
commissioners.
The Trust has taken the following actions to improve the indicator and percentage in a and b, and so the quality
of its services by:
••
A number of improvement projects have been commenced assessing both data quality and clinical care, this is
available within an extensive action plan which is in place to address the higher than expected SHMI, just some
of the key points are outlined as follows
53
Annual Quality Account 2012/13
••
A monthly mortality report is produced which provides the mortality performance committee (MPC) and the
Trust Board with a monthly breakdown of the Trust’s performance with mortality and an outline of some of the
work streams underway to improve this area
••
Patients who have died within the organisation are reviewed using the mortality trigger tool with a view to
identifying any cases requiring more detailed clinician review by a senior medic or a senior nurse
••
As a result of the findings from such quality evaluation work and the monthly data reporting within the
mortality report, specific pathway areas are being identified and where necessary quality improvement
projects are being developed focussing on the pathway of care and the other key ‘action themes’ from the
trigger tool review work
••
An external review of the Trust’s assurance mechanisms is planned to take place during May by KPMG
••
The Trust is one of the 14 Trusts involved in the Keogh Review which will review:
••
Whether existing action by these Trusts to improve quality is adequate and whether any additional steps
should be taken
••
Any additional external support that should be made available to the Trust to help improve
••
Any areas that may require regulatory action in order to protect patients.
2.3l: Patient Reported Outcome Measures (PROMS)
The data made available to the Trust by the Health and Social Care Information Centre with regard to the Trust’s
patient reported outcome measures scores for:
a)
Groin hernia surgery
b) Varicose vein surgery
c)
Hip replacement surgery
d) Knee replacement surgery
during the reporting period.
Type of surgery
Groin hernia
Varicose vein
Hip replacement
Knee
replacement
54
Trust adjusted
average health
gain
National
average
health gain
National
highest
National
lowest
April 2010 – March 2011
0.121
0.085
0.156
-0.020
April 2011 – March 2012
0.084
0.087
0.143
-0.002
0.091
0.155
-0.007
0.094
0.167
0.047
Sample time frame
April 2010 – March 2011
April 2011 – March 2012
Not available
April 2010 – March 2011
0.438
0.405
0.503
0.264
April 2011 – March 2012
0.405
0.416
0.532
0.306
April 2010 – March 2011
0.316
0.299
0.407
0.176
April 2011 – March 2012
0.317
0.302
0.385
0.180
Source: NHS information centre
Comment: The above table shows the Trust’s reported adjusted health gain, which is a measure of the patient’s
own reported outcome following surgery within the Trust. The Patient Reported Outcome Measure (PROM)s is
a national initiative designed to enable NHS trusts to focus on patient experience and outcome measures. The
four areas listed above are nationally selected procedures of which the Trust has no power to influence. This is
illustrated in varicose vein surgery, which the Trust does not provide hence why no data is available.
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust considers that the outcome scores are as
described for the following reasons:
••
For some years the Trust has monitored its participation rates and response rates in relation to the completion
of pre-operative and post-operative PROMs questionnaires. These rates have been positive when compared
to peers within the Yorkshire and Humber region. Quarterly reports are now received from the Quality
Observatory that provide progress updates on both the participation rates and the overall health gain
reported by patients. The figures noted above evidence the positive performance of the Trust in relation to
overall health gain with health gain scores for hip replacement falling slightly below the national average.
The Trust has taken the following actions to improve these outcome scores, and so the quality of its services by:
The results have been discussed at the surgery and critical care clinical governance group with clinical leads being
identified to lead further review work. This additional detailed analysis of patient level data will assist clinical
teams to drive further improvements in patient reported outcomes
The Trust will also continue to monitor the rate of participation for each clinical procedure and encourage patient
participation before and after surgery.
2.3m: Readmissions to hospital
The data made available to the Trust by the Health and Social Care Information Centre with regard to the
percentage of patients aged:
a)
0 to 14; and
b) 15 or over.
Readmitted to a hospital which forms part of the Trust within 28 days of being discharged from a hospital which
forms part of the Trust during the reporting period.
Age group
0 to 14
15 or over
Emergency
readmissions (%)
2010/2011
National
re-admissions (%)
National
highest (%)
National lowest
(%)
8.19%
10.15%
25.80%
0.00%
2009/2010
7.93%
10.18%
31.40%
0.00%
2008/2009
7.59%
10.09%
22.73%
0.00%
2010/2011
9.18%
11.42%
22.93%
0.00%
2009/2010
8.92%
11.16%
22.09%
0.00%
2008/2009
8.64%
10.90%
29.42%
0.00%
Time frame
Source: NHS information centre
Comment: The above table outlines the percentage rate of emergency admissions to the Trust within two
primary age groups (1) 0 – 14 years and (2) 15 years or over. The table also provides peer data with which the Trust
can benchmark itself. The table illustrates that the rate of emergency re-admissions within the Trust is lower than
that of the national average.
55
Annual Quality Account 2012/13
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust considers that these percentages are as
described for the following reasons:
••
The Trust has been consistently below the national rates for re-admissions.
The Trust intends to take the following actions to improve these percentages, and so the quality of its services by:
••
The Trust will continue to monitor re-admissions to maintain performance however recognises that readmissions may see a small increase as ambulatory care and short stay models continue to be implemented.
2.3n: Personal needs of patients
The data made available to the Trust by the Health and Social Care Information Centre with regard to the Trust’s
responsiveness to the personal needs of its patients during the reporting period.
Average weighted
score of 5
questions
National average
National highest
National lowest
2011/2012
69.0
67.4
85.0
56.5
2010/2011
67.8
67.3
82.6
56.7
2009/2010
67.6
66.7
81.9
58.3
Time frame
Source: NHS information centre
Comment: The table above highlights the average weighted score for five specific questions. This information is
presented in a way that allows comparison to the national average and the best and worst performers within the
NHS.
The above Figures are based on the adult inpatient survey, which is completed by a sample of patients aged
16 and over who have been discharged from an acute or specialist trust, with at least one overnight stay. The
indicator is a composite, calculated as the average of five survey questions from the inpatient survey. Each
question describes a different element of the overarching theme, “responsiveness to patients’ personal needs”.
1.
Were you involved as much as you wanted to be in decisions about your care and treatment?
2.
Did you find someone on the hospital staff to talk to about your worries and fears?
3.
Were you given enough privacy when discussing your condition or treatment?
4.
Did a member of staff tell you about medication side effects to watch for when you went home?
5.
Did hospital staff tell you who to contact if you were worried about your condition or treatment after you
left hospital?
Individual questions are scored according to a pre-defined scoring regime that awards scores between 0-100.
Therefore, this indicator will also take values between 0-100.
For each provider an average weighted score (by age and sex) is calculated for each of the questions. Trust scores
are calculated from a simple average of the question scores. National scores are calculated by a simple average of
the trust scores.
56
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust considers that this data is as described for the
following reasons:
••
The Trust has continued to achieve results that are above the national average and has made positive progress
each year. Performance against the first four questions noted above has been monitored on a monthly basis
by the quality matrons who have surveyed 10 patients on each ward per month, the outcome being published
on the monthly nursing dashboard. This has enabled wards and departments to review progress and identify
areas for improvement.
The Trust has taken the following actions to improve this data, and so the quality of its services by:
The quality matrons will continue to review the Trust’s performance in relation to the personal needs of patients
and will also develop systems to ensure that appropriate contact information is given to patients on discharge.
News release:
Patients needing joint replacement surgery are recovering quicker and being sent home sooner than
traditionally with the introduction of a new way of working.
People being admitted to Scunthorpe General Hospital for hip and knee replacements are taking part in
an enhanced recovery after surgery programme.
This programme of care – which hinges on patients being active participants before, during and after their
surgery – aims to help people recover quickly and safely after surgery.
Orthopaedic consultant Mr Peter Molitor said: “As soon as people hear they need a joint replacement they
automatically think they will be off their feet for a prolonged period of time. However, it is no longer a case
of them coming in, getting in their pyjamas and then being in bed for two weeks.
“Now they come into hospital, walk to theatre if they are able to do so, and on the same day of their
procedure they get out of bed and use their new joint. They are encouraged to walk about, as the faster
they mobilise, the better it is for their recovery.”
Patients are often anxious about having undergone major surgery and what pain they will experience.
However, the programme ensures they receive clear education and information in clinic and at their preassessment, and they are advised of their estimated length of stay in hospital and their date of discharge.
In the past, stays in hospital after joint replacement were between 10 to 14 days. On average they are now
four to five days but with this new programme they can be as low as two to three days.
From a surgical approach, the operation is no different, but the anaesthetic technique has to be modified.
Mr Molitor said: “Patients on the programme receive a spinal anaesthetic and specific analgesics. They also
receive local anaesthetic directly into the area where the new joint has been inserted. All of these things
mean they recover more quickly after the operation.”
A multi-disciplinary team works with patients. This includes surgeons, anaesthetists, physiotherapists,
discharge planning team, pre-assessment nurses, theatre nurses and ward staff.
Mr Molitor added: “Using the enhanced recovery after surgery programme means patients recover quickly
following their operation and they can be discharged from hospital and go home, as soon as it is safe for
them to leave.”
57
Annual Quality Account 2012/13
2.3o: Staff recommending Trust as a provider to friends and family
The data made available to the Trust by the Health and Social Care Information Centre with regard to the percentage
of staff employed by, or under contract to, the Trust during the reporting period who would recommend the Trust
as a provider of care to their family or friends.
Trust
performance
(%)
National average
(acute Trusts) (%)
National highest
(acute Trusts)
(%)
National lowest
(acute Trusts) (%)
2012
55%
65%
94%
35%
2011
54%
62%
89%
33%
2010
54%
63%
89%
38%
Staff Survey Year
Source: NHS information centre
Comment: The above table illustrates the percentage of staff answering that they “agreed” or “strongly agreed”
with the question: “If a friend or relative needed treatment, I would be happy with the standard of care provided
by this Trust”.
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust considers that this percentage is as described for
the following reasons:
••
The Trust is asking ward staff as part of monthly data collection information via the nursing dashboard specific
questions regarding their ability to deliver the care they wanted to and if they would recommend their ward to
family, appropriate action is taken as a result of this
••
Based on the most recent analysis of this data, between September 2012 and April 2013, 1,588 staff would
definitely be happy for a friend or family member to receive care on their ward. 503 staff would to some extent
be happy for a friend or family member to receive care on their ward. Only 12 staff would not recommend their
ward. This positive feedback equates to a percentage of 99.4 % of staff who would be happy for a friend or
family member to receive care on their ward
••
Staff are also asked if they are satisfied with the care they provide. In response, 1,408 staff are definitely
satisfied with the care they provided. 673 were to some extent satisfied with the care they provided. Only 22
staff where not satisfied with the care provided. This equates to a percentage of 99% of staff who are satisfied
with the care they provide.
The Trust has taken the following actions to improve this percentage, and so the quality of its services by:
••
The Trust is participating in the friends and family test and will be reporting on this monthly through the
quality report during 2013/14
••
The organisational development and workforce strategy seeks to motivate staff, stimulate performance, place
patients first and drive quality into service delivery. To achieve this strategy the question of a correctly aligned
culture becomes relevant. Consequently an organisation wide culture assessment has been undertaken
••
During this exercise the Morale Barometer was created. The Morale Barometer is an in-house staff survey tool,
locally designed, which looks to determine, at any given time, what is motivating and demotivating staff. The
tool also provides a morale gauge to evaluate workforce mood and satisfaction
58
••
The Morale Barometers baseline survey findings became available November 2012. From this, coupled with
the outputs from the other culture assessment tools, it has been possible to configure three work streams
to stimulate the high performing culture and stimulate/maintain the evident workforce satisfaction and
motivation. These three work streams are:
1.
Social movement and workforce resilience: To established a common purpose, improve morale and
invest in enhanced change management process
2.
Leadership style and workforce development: To increase staff engagement, deliver an ’inclusive’
management style, increase safety, and develop internal career progression pathways
3.
Reward and recognition: To reward and acknowledge staffing achievements, drive quality and
stimulate NHS family inclusivity
2.3p: Risk assessed for venous thromboembolism
The data made available to the Trust by the Health and Social Care Information Centre with regard to the percentage
of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the
reporting period.
Trust
performance
(%)
National average
(Acute providers)
(%)
National highest
(Acute providers)
(%)
National lowest
(Acute providers)
(%)
Q3 2012/12
94.4%
94.1%
100%
84.6%
Q2 2012/13
93.2%
93.8%
100%
80.9%
Q1 2012/13
92.8%
93.4%
100%
80.8%
Q4 2011/12
90.8%
92.5%
100%
69.8%
Q3 2011/12
81.0%
90.7%
100%
32.4%
Q2 2011/12
82.5%
88.2%
100%
20.4%
Q1 2011/12
80.1%
84.1%
100%
15.7%
Q4 2010/11
51.2%
80.8%
100%
11.1%
Q3 2010/11
42.9%
68.4%
100%
0%
Q2 2010/11
38.5%
52.5%
100%
0%
Quarter / Year
Source: NHS information centre
Comment: The above table illustrates the percentage of patients admitted to the Trust and other NHS acute
healthcare providers who were risk assessed for venous thromboembolism (VTE) since quarter two, 2010/11. As
illustrated in the above table the Trust has consistently achieved above 90 per cent since quarter four, 2011/12 and
is now performing on par with the national average for this indicator.
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust considers that this percentage is as described for
the following reasons:
••
The Trust has made great improvements in VTE prophylaxis in the last three years, and is currently meeting the
Commissioning for Quality and Innovation Scheme (CQUINs) target of 90 per cent.
The Trust has taken the following actions to improve this percentage, and so the quality of its services by:
••
The Trust reports VTE prophylaxis rates by ward and had action plans to improve those wards with lower rates.
These are constantly monitored and re-visited as required.
59
Annual Quality Account 2012/13
2.3q: Clostridium difficile infection reported within the Trust
The data made available to the Trust by the Health and Social Care Information Centre with regard to the rate per
100,000 bed days of cases of clostridium difficile infection reported within the Trust amongst patients aged two or
over during the reporting period.
Trust performance
per 100,000 bed
days
National average
per 100,000 bed
days
National highest
per 100,000 bed
days
National lowest
per 100,000 bed
days
April 2011 – March 2012
19.5
21.8
51.6
0
April 2010 – March 2011
19.1
29.6
71.8
0
April 2009 – March 2010
20.5
36.7
85.2
0
Time frame
Source: NHS information centre
Comment: The above table illustrates the rate of clostridium difficile per 100,000 bed days for specimens taken
from patients aged two years and over. The downward trend from the first available data in 2009 is discernible from
this table and the Trust compares favourably to the national average for this indicator.
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust considers that this rate is as described for the
following reasons:
••
The Trust has made considerable progress in reducing the number of Clostridium difficile cases and is below
the national average. Cases that are deemed to be unavoidable now significantly outnumber those cases felt
to be at least partially avoidable. Nevertheless, work continues to reduce these still further.
The Trust has taken the following actions to improve this rate, and so the quality of its services by:
••
The Trust has an evidence based clostridium difficile policy and patient care pathway
••
Multi-disciplinary team meetings are held for inpatient cases to identify any lessons to be learnt and root cause
analysis is conducted for every hospital acquired case and a director of infection prevention and control (DIPC)
review is held where there has been a breach in practice or the patient has died
••
For each case admitted to hospital, practice is audited by the infection prevention and control team using the
Department of Health Saving Lives’ audit tools
••
Development of a Trust-wide clostridium difficile prevention action plan which is monitored monthly by the
Trust Board and infection control committee
••
Monthly meetings of site specific clostridium difficile action groups whose remit is to review each case and
monitor site specific trends and themes. Local action plans are produced and monitored
••
Production of a dash board to monitor compliance with the routine deep clean schedule reviewed by the site
specific clostridium difficile action group
••
Introduction of a training programme that purely focuses on clostridium difficile issues and care. To support
this a monitoring and feedback mechanism to managers regarding the number of staff attending these
sessions has been developed
••
Introduced an alert sticker for patient medical notes and to fit in with the Trust direction of travel in connection
with the development of the Electronic Patient Record, ensured that a clostridium difficile alert icon has been
built in to the system being used to host this development
••
Introduction of a specific clostridium difficile discharge letter that is sent to GP’s informing them of the patients
result and informing them of the potential future risks for the patient
••
Introduction of an antimicrobials steering group to monitor the antibiotic side of the clostridium difficile
agenda
••
Development and implementation of a rolling programme of antibiotic prescribing audits which are reviewed
by the steering group and the site specific clostridium difficile action groups
••
Appointed a non-executive director (NED) lead for the infection control committee.
60
••
Introduced an infection prevention and control zero tolerance approach (documentary evidence available)
••
Development of policies and communication aids for the admission, outlying and transferring of patients with
infectious diseases
••
To ensure the right level of challenge the infection control committee has formally been made a subcommittee of the Board.
2.3r: Patient safety incidents
The data made available to the Trust by the Health and Social Care Information Centre with regard to:
a).
The number and, where available, rate of patient safety incidents reported within the Trust during the reporting period,
Trust Number
of patient
safety
incidents
reported
Trust Rate of
patient safety
incidents
reported
per 100
admissions
Large Acute
Trust National
rate of patient
safety incidents
reported per 100
admission
Large Acute
National
highest
rate per 100
admissions
Large Acute
National
lowest rate
per 100
admissions
October 2012 –
March 2013
4,941*
Not available*
Not available*
Not available*
Not available*
April 2012 –
September 2012
4,487
8.78
6.69
13.61
1.99
October 2011 –
March 2012
4,217
8.41
6.22
9.75
1.93
April 2011 –
September 2011
4,033
8.04
5.99
10.08
2.75
October 2010 –
March 2011
3,733
7.25
5.62
9.91
1.79
April 2010 –
September 2010
3,626
7.04
5.25
8.65
1.71
October 2009 –
March 2010
3,069
5.92
5.49
9.19
2.10
Time frame
Source: March 2010 – April 2012, NHS Information Centre, October 2012 – March 2013, DATIX
* For the purposes of this report, as national comparative data is unavailable on the NHS Information Centre’s Portal
for the most recent period (October 2012 – March 2013) local data from DATIX has been used to indicate the number of
patient safety incidents. As the national data is unavailable, only the actual number of incidents reported is available.
Comment: The above table demonstrates the total number and rate per 100 admissions of patient safety
incidents reported within the period of October 2009 – March 2012. Northern Lincolnshire and Goole Hospitals
NHS Foundation Trust average rate of patient safety incidents reported is above the average of other large acute
NHS organisations. Within the Trust staff are encouraged to report all incidents, therefore this number should be
seen as encouraging that any concern what so ever regarding patient safety is reported for internal escalation
and investigation and for remedial action to be taken to ensure any concerns are learnt from thus reducing the
chance of these incidents replicating themselves and leading to patient harm.
The Trust is continuing to actively encourage and promote incident reporting, and therefore expects the number
of incidents reported to remain high and potentially increase in number in order to continue the work streams
focussing on learning from incidents. The emphasis continues on reducing harm from patient safety incidents,
the number and percentage in figure b) below demonstrates this.
b).
And the number and percentage of such patient safety incidents that resulted in severe harm or death.
61
Annual Quality Account 2012/13
Trust Number
of patient
safety
incidents
reported
involving
severe harm or
death
Trust Rate of
patient safety
incidents
reported
involving
severe harm
or death
(%)
Large Acute
Trust National
average of
patient safety
incidents
reported
involving severe
harm or death
(%)
Large Acute
Trust National
highest rate
involving
severe harm or
death
(%)
Large Acute
Trust National
lowest rate
involving
severe harm or
death
(%)
October 2012 –
March 2013
4*
0.08%
Not available*
Not available*
Not available*
April 2012 –
September 2012
8
0.17%
0.71%
2.50%
0.00%
October 2011 –
March 2012
10
0.24%
0.75%
3.26%
0.00%
April 2011 –
September 2011
8
0.20%
0.77%
2.88%
0.10%
October 2010 –
March 2011
5
0.13%
0.92%
4.01%
0.05%
April 2010 –
September 2010
6
0.17%
0.75%
2.95%
0.02%
October 2009 –
March 2010
9
0.29%
0.64%
1.63%
0.05%
Time frame
Source: March 2010 – April 2012, NHS Information Centre, October 2012 – March 2013, DATIX
* For the purposes of this report, as national comparative data is unavailable on the NHS Information Centre’s Portal
for the most recent period (October 2012 – March 2013) local data from DATIX has been used to indicate the number of
patient safety incidents. As the national data is unavailable, only the actual number of incidents reported and the Trust’s
rate is available.
Comment: The above table demonstrates the total number and rate per 100 admissions of patient safety incidents
involving severe harm or death reported within the period of October 2009 – March 2012. Northern Lincolnshire
and Goole Hospitals NHS Foundation Trust has a lower than national average of patient safety incidents reported
involving severe harm or death.
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust considers that this data is as described for the
following reasons:
••
The Trust undertakes regular analysis of incident data, producing a wide range of monthly, quarterly and
annual analysis reports which are shared throughout the organisation via a number of committees/groups/
forums. These reports enable aggregate analysis of data, along with analysis of particular hot-spots and trends.
The relevant group/committee review the reports, and consider recommendations, which look to improving
patient safety and addressing known risks identified in these reports.
The Trust has taken the following actions to improve this number and/or rate, and so the quality of its services by:
••
The Trust has formed a number of multi-disciplinary groups focussing on prevention initiatives to reduce
the harm from patient safety incidents, and also to reduce the number of incidents. Examples of these work
streams are the safer medication group which has a formal work programme in place which is taking forward a
number of initiatives and is reviewed on an annual basis to ensure these remain relevant and targeted against
known risks.
••
The Trust falls prevention group has in place an action plan incorporating and integrating patient safety
preventing harm from falls initiatives, environmental risk assessments and health and safety risk management
initiatives, all targeted on reducing risk and preventing harm to patients. A key focus group is the learning
lessons review group which had developed a formal action plan incorporating a number of patient safety
initiatives, including actions to address patient mis-identification.
62
News release:
Patients put hydration system on trial
Patients at Scunthorpe General Hospital are among the first in the country to trial a new system that aims
to improve hydration levels and access to fluids.
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust is among 50 Trusts in the country to be
chosen to take part in a national pilot project, run by the Department of Health.
Three wards are participating in the pilot – 11, 17 and 24, the orthopaedic, diabetes/endocrinology, and
cardiac wards. Instead of the traditional cups that might be difficult for patients to reach or are easy to
knock over, patients will have their own water bottles clipped to their beds and drinking tubes that they
can use to take a sip of their drink whenever they want one.
The inventor of the device, Mark Moran, was born in Grimsby. He came up with the idea after suffering
from a spinal injury five years ago. He said: “I was laid flat on my back in hospital unable to move and I
couldn’t get a drink. Even if I’d been able to reach the cup, I probably wouldn’t have been able to lift it and I
didn’t want to bother staff as they were really busy.”
Quality matron Hazel Moore, who leads on nutrition and hydration for the Trust, said: “The Hydrant system
is very similar to the water bottles that sports people use when they’re on the move and need easy access
to fluids. This bottle can be clipped securely to a wheelchair or bed, and the tube can be positioned within
easy reach of the patient so they can take a sip without having to call a member of staff to help them.
“Good fluid management is essential and we’re confident this system will benefit our patients. Being
unable to reach a drink can be frustrating and can also lead to dehydration, which can be very serious.
Proper hydration reduces the chance of infection and other illnesses developing, and speeds up recovery.”
The bottles can hold one litre of cold or warm fluid. The drinking tube has a bite valve and a small clip to
attach the tube to clothing if required. The bottle is hung from the bed, chair or wheelchair and the patient
simply takes hold of the tube, inserts the bite valve between their lips then bites and sucks. The bite valve
opens under pressure and closes when released so there is no leakage.
Jean Ward was the first patient to trial the Hydrant system at the Trust. Having suffered a stroke she finds
it difficult to sit up. She said: “I think it’s fantastic, it has made such a difference and has given me a bit of
independence back. It’s so much better than using the beaker, which was easy to spill. It’s great to be able
to have a drink when I want one without having to move and reach for a cup, or call a nurse.”
The Trust will monitor the system and collect data from patients and staff, which will be fed back to the
Department of Health. At the end of the pilot, the Trust will decide whether or not to roll out the Hydrant
system to other wards across its three hospitals.
63
art 3: An overview of the quality of care based on
Annual Quality Account 2012/13
erformance in 2012/13 against indicators
Part 3: An overview of the quality of care based on 1 Performance
against 2012/13 indicators
performance in 2012/13 against indicators
rts 2.1a, 2.1b and 2.1c of this report outlined progress during 2012/13 towards achieving
priorities for this financial year just ended which the Trust set out in its previous Annual
3.1 Performance against 2012/13 indicators
ality Account for 2011/12. The quality priorities in part two were presented in three distinct
Parts 2.1a,
2.1b and 2.1c of this
report outlined
during
2012/13
towards
achieving
the priorities
for this
ctions: clinical
effectiveness
(2.1a),
patientprogress
safety
(2.1b)
and
patient
experience
(2.1c).
financial year just ended which the Trust set out in its previous Annual Quality Account for 2011/12. The quality
priorities in part
two were presented
three distinct
sections:
clinicalcontained
effectiveness (2.1a),
patient
safety
(2.1b) 2.1b
r these indicators
selected
by the inTrust,
the full
report,
within
parts
2.1a,
and
patient
experience
(2.1c).
d 2.1c refer to benchmarked data, where available, to enable performance compared to
er providers.
to bythe
datathesources
are
also
stated
For theseReferences
indicators selected
the Trust,
full report, used
contained
within
parts
2.1a, 2.1bwithin
and 2.1c these
refer to earlier
benchmarked
data,
where
available,
to
enable
performance
compared
to
other
providers.
References
to the data by
rts of this report and where relevant this includes whether the data is governed
sources
used
are
also
stated
within
these
earlier
parts
of
this
report
and
where
relevant
this
includes
whether
the
ndard national definitions.
data is governed by standard national definitions.
ring 2012/13 the following quality priorities were monitored by the monthly quality report
During 2012/13 the following quality priorities were monitored by the monthly quality report which was
ich was presented
presented
and reviewed on a monthly basis by the Trust’s quality and patient
and reviewed on a monthly basis by the Trust’s quality and patient experience (QPEC) committee and
perience the
(QPEC)
committee
the performance
Trust Board.
A these
summary
of the
Trust’s
Trust Board. A summary ofand
the Trust’s
against
key indicators
(outlined
withinperformance
part two in
ainst these
indicators
(outlined within part two in full) are summarised below:
full) key
are summarised
below:
nical effectiveness:
Clinical effectiveness:
QUALITY INDICATORS AT A GLANCE
2012/13 Indicators
Period
Indicator
Jan‐13
Prev 12 mths (average)
Threshold
89
94
100
106
125
100
91
91
100
84
93
100
Mar‐13
Prev 12 mths (average)
Threshold
100.0%
98.6%
95.0%
Change
Feb‐13
Prev 12 mths (average)
Threshold
‐4.8%
‐4.6%
10.0%
1.9%
‐0.9%
16.0%
95.0%
93.0%
100.0%
94.0%
93.0%
100.0%
99.8%
97.6%
90.0%
92.1%
93.9%
84.0%
Change
Dec‐12
Change
CLINICAL EFFECTIVENESS
Trust RAMI reduction of 10 points and CE1a
downward trajectory
Trust Stroke RAMI reduction of 10 points CE1b
and downward trajectory
Trust Cardiac conditions RAMI reduction CE1c
of 10 points and downward trajectory
Trust Respiratory RAMI reduction of 10 CE1d
points and downward trajectory
#
Change
CE2
Implement 'Check Your Charts' element of the Patient Safety First Campaign
CE3 Patient Observations
CE4 NEWS Scoring CE5
Emergency Re‐admissions (dementia)
DPoW
SGH
GDH
DPoW
SGH
GDH
DPoW
SGH
GDH
3.5%
13.0%
13.0%
Change
CE6
Length of stay (dementia)
DPoW
SGH
GDH
Dec‐12
11.8
11.2
10
Prev 12 mths (average)
14.2%
14.8%
15.1%
Prev 12 mths (average)
9.1
7.1
9.4
95.0%
95.0%
Threshold
Downward trajectory
Threshold
Downward trajectory
64
ctorate of Clinical and Quality Assurance, April 2013
Page 74 of 97
Patient safety:
Patient safety:
Patient safety:
QUALITY INDICATORS AT A GLANCE
2012/13 Indicators
QUALITY INDICATORS AT A GLANCE
2012/13 Indicators
Indicator
Period
Indicator
Period
Mar‐13
PATIENT SAFETY
MRSA Bacteraemia Incidence
PS1
PATIENT SAFETY
C Difficile Incidence
PS2
PS1 MRSA Bacteraemia Incidence
PS2 C Difficile Incidence
Mar‐13
0
40
4
Jan‐13
Jan‐13
PS3
All patient identification incidents
PS3
PS5
All patient identification incidents
5% reduction in falls per 1,000 bed days
PS5
PS6
5% reduction in falls per 1,000 bed days
5% reduction in the number of repeat fallers per 1,000 bed days
5% reduction in the number of repeat fallers per 1,000 PS6
PS7
PS7
20
20
9.1
9.1
1.25
bed days
100% compliance undertaking RCA for repeat fallers
1.25
100.0%
100% compliance undertaking RCA for repeat fallers
100.0%
Feb‐13
PS8
5% reduction in pressure ulcers per 1,000 bed days
PS8
5% reduction in pressure ulcers per 1,000 bed days
Patient experience:
Patient experience:
Patient experience:
Feb‐13
Prev 12 mths (average)
Prev 12 mths (average)
2
37
2
Threshold
Threshold
No more than 3
No more than 34
No more than 3
37
No more than 34
Prev 12 mths Threshold
(average)
Prev 12 mths Threshold
5% reduction (18 (average)
19
per mth)
5% reduction (18 19
5% reduction per mth)
7.8
(7.4 target)
5% reduction 7.8
5% reduction (7.4 target)
1.10
(0.96 target)
5% reduction 1.10
(0.96 target)
50.0%
100.0%
50.0%
Prev 12 mths (average)
Prev 12 mths 2.1
(average)
0.8
2.1
0.8
100.0%
Threshold
Threshold
5% reduction (0.67 target)
5% reduction (0.67 target)
QUALITY INDICATORS AT A GLANCE
2012/13 Indicators
QUALITY INDICATORS AT A GLANCE
Indicator
2012/13 Indicators
Period
Prev 12 mths (average)
Prev 12 mths Indicator
Change
Period
Feb‐13
PATIENT EXPERIENCE
Overall satisfaction with Trust services
PE1
PATIENT EXPERIENCE
Overall satisfaction with Trust services
PE1 Recommending the Trust to family and PE2
friends
Recommending the Trust to family and PE2
friends
Change
Feb‐13
8.0%
95.0%
(average)
87.0%
8.0%
4.0%
95.0%
98.0%
87.0%
94.0%
85%
90%
4.0%
98.0%
90%
Change
Mar‐13
Threshold
Change
1.0%
94.0%
Prev 12 mths (average)
Prev 12 mths 100.0%
(average)
99.0%
95%
1.0%
100.0%
Change
Feb‐13
Change
7.6%
6.4%
7.6%
4.4%
6.4%
12.9%
4.4%
23.5%
12.9%
14.8%
23.5%
8.7%
14.8%
6.6%
8.7%
9.6%
6.6%
Feb‐13
100.0%
99.0%
100.0%
100.0%
99.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
97.0%
100.0%
94.0%
97.0%
98.0%
94.0%
99.0%
Prev 12 mths (average)
Prev 12 mths 92.4%
(average)
92.6%
92.4%
95.6%
92.6%
87.1%
95.6%
76.5%
87.1%
85.2%
76.5%
88.3%
85.2%
87.4%
88.3%
88.4%
87.4%
9.6%
98.0%
88.4%
PE3
PE3
Complaints responded to within agreed timescales Complaints responded to within agreed timescales PE4
Care and treatment
PE4
Care and treatment
PE5
Medication side effects
PE5
Medication side effects
PE6
Nursing care indicator
PE6
Nursing care indicator
DPoW
SGH
DPoW
GDH
SGH
DPoW
GDH
SGH
DPoW
GDH
SGH
DPoW
GDH
SGH
DPoW
GDH
SGH
GDH
Mar‐13
Threshold
Threshold
85%
Threshold
95%
Threshold
Threshold
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
65
3.2 Performance
against relevant
indicators and
Annual
Quality
Account
2012/13
performance thresholds
3.2 Performance
Performance
against relevant indicators against the relevant indicators and performance thresholds set out in Appendix
Band
of theperformance
Compliance Framework.
thresholds
Performance against the relevant indicators and performance thresholds set out in Appendix B of the Compliance
Northern Lincolnshire and Goole Hospitals
Framework.
NHS Foundation Trust
NHS
MONITOR COMPLIANCE FRAMEWORK SUMMARY
Performance Against Key Thresholds For The Period 1st April 2012 To 31st March 2013
TARGET
2011/12
2012/13
2012/13
2012/13
QTR 4
QTR 1
QTR 2
QTR 3
WEIGHTING
QTR 4
THRESHOLD TO DATE
QTR 4
ACTUAL TO DATE
FAILURE WEIGHTING
Infection Control *
1
MRSA Bacteraemia
G
G
G
G
1.0
3
3
G
2
Clostridium Difficile
R
G
G
G
1.0
34
37
R
Referral to Treatment Waiting Times
3
Admitted ‐ Maximum waiting time of 18 weeks
G
G
G
G
1.0
90.0%
96.0%
G
4
Non‐admitted ‐ Maximum waiting time of 18 weeks
G
G
G
G
1.0
95.0%
98.0%
G
5
Incomplete ‐ Maximum waiting time of 18 weeks
G
G
G
G
1.0
92.0%
97.3%
G
Cancer
6
31 day wait diagnosis to treatment
G
G
G
G
0.5
96.0%
100.0%
G
7 i)
31 day wait for subsequent treatments ‐ Surgery
G
G
G
G
1.0
94.0%
100.0%
G
G
G
G
G
98.0%
100.0%
G
G
G
G
G
1.0
85.0%
91.9%
G
G
G
G
G
90.0%
100.0%
G
G
G
G
G
93.0%
98.6%
G
G
G
G
R
93.0%
95.2%
G
G
G
G
G
1.0
95.0%
92.3%
R
1.0
ii) 31 day wait for subsequent treatments ‐ Anti cancer drugs
8 i)
62 day wait GP referral to treatment
ii) 62 day wait Consultant screening service referrals
9 i)
2 week wait referral to consultation
ii) 2 week wait breast symptom referrals
0.5
A&E
10
A&E 4 Hour Wait Compliance
Data Completeness Community Services
11 i)
N/A
G
G
G
50.0%
96.0%
G
ii) Referral Information
Referral to treatment information
N/A
G
G
G
50.0%
92.0%
G
iii) Treatment Activity Information
N/A
G
G
G
50.0%
92.0%
G
G
G
G
G
Y/N
Y
G
Access **
12
Access to healthcare for people with learning disability
0.5
* Cumulative figures
Total Monitor Compliance Score
** Annual
Monitor Compliance Rating
2.0
Amber Red
Additional community care data completeness indicators:
Additional community care data completeness indicators:
Q4 Threshold To
Q4 Actual To Date
Q4 ThresholdDate
To
Q4 Actual To Date
Date
Patient identifier completeness
50%
100%
Patient identifier completeness
50%
100%
End of life patients deaths at home information completeness
50%
80.65%
End of life patients deaths at home information completeness
50%
80.65%
NB:wait
31-day
wait
for second
or subsequent
treatment iscomprising
NB: 31-day
for second
or subsequent
treatment
comprising radiotherapy
not applicableradiotherapy
to the Trust as is not
applicable
to the Trust
radiotherapy
is not provided
withinas
theradiotherapy
organisation. is not provided within the organisation.
For full details and technical specifications from Monitor guiding NHS Trusts how compliance with the above is to
For full details and technical specifications from Monitor guiding NHS Trusts how compliance
be calculated, please see annex 8.
with the above is to be calculated, please see annex 8.
Directorate of Clinical and Quality Assurance, April 2013
66
Page 76 of 97
3.3 Information on staff survey report
Commentary
All Trusts are required to undertake a national staff survey in order to determine their staffs perceptions of the
Trust as an employer and healthcare provider. Historically the Trust has undertaken a full census survey of all staff
but this year moved to a sample survey.
The results of the 2012 staff survey have recently become available from which a summary is provided below.
Summary of performance - NHS staff survey
Details of the key findings from the latest NHS staff survey:
••
Response rate compared with prior year:
2011/12
Response rate
Trust improvement/
deterioration
2012/13
Trust
National
average
Trust
National
average
34%
54%
30%
51%
••
Areas of improvement from the prior year and deterioration
••
Top four ranking scores:
2011/12
Top 4
4% deterioration
Trust improvement/
deterioration
2012/13
ranking scores
Trust
National
Average
Trust
National
Average
% of staff having well structured
appraisals in last 12 months
21%
34%
21%
36%
No change
% of staff agreeing that their
role makes a difference to
patients
89%
90%
84%
89%
5% decrease
% of staff appraised in last 12
months
61%
81%
64%
84%
3% increase
% of staff receiving health and
safety training in last 12 months
76%
81%
62%
74%
14% decrease
67
Annual Quality Account 2012/13
••
Bottom four ranking scores:
2011/12
Bottom 4
Trust improvement/
deterioration
2012/13
Trust
National
average
Trust
National
average
% of staff experiencing physical
violence from patients, relatives
or the public in last 12 months
4%
8%
9%
15%
5% increase
% of staff experiencing
harassment, bullying or abuse
from patients, relatives or the
public in last 12 months
10%
15%
23%
30%
13% increase
% of staff experiencing physical
violence from staff in last 12
months
0%
1%
2%
3%
2% increase
% of staff experiencing
harassment, bullying or abuse
from staff in last 12 months
15%
16%
22%
24%
7% increase
ranking scores
Work toward addressing the above concerns has commenced. This work includes developments within the
internal marketing of the staff survey to staff response rates for future years and a significant investment to review
the appraisal process.
Reviewing the total findings of the staff survey has determined that there is significant synergy between the
outcomes of the staff survey and requirements to address any concerns in the survey and the Trust’s established
culture change action plan (2012).
The culture action plan, endorsed and committed to by the Trust Board focuses on three dominant work streams,
these being:
••
Social movement and workforce resilience
••
Leadership style and workforce development
••
Reward and recognition.
Combined these three work streams are designed to establish a common purpose through our (soon to be
launched) vision and values, to stimulate and improve morale and to review and enhance how we enact change
management process.
The work streams proactively stimulate staff engagement through initiatives such as ‘An Audience with Karen’,
‘Meet the Chief’ and the ‘Dragons Den’. To compliment this we are investing heavily in internal communications
and marketing to increase staff awareness of Trust developments and the opportunities available to them, such as
those mentioned above.
Turning towards leadership and management style we are reviewing our internal leadership development
programmes in order to achieve a greater team orientated, motivational, engaging and inspirational
management style. Complementing this investment in management and leadership style and skills the work
streams also inject investment in the internal career progression for all staff through the establishment of
an internal coaching and mentoring network and the establishment of value led recruitment and value led
appraisals, the later interventions coming later this calendar year.
Finally the Trust has placed an increased focus on workforce total reward and recognition. The revised reward
and recognition strategy is designed to not only acknowledge staffing achievements, drive quality and stimulate
NHS Family inclusivity but to also provide rewards which stimulate the desired behaviours which feature in the
organisations identified high performing culture.
••
Key areas of improvement
••
Summary details of any local surveys and results (if applicable); and
••
Areas of concern and action plans to address.
68
Future priorities and targets
••
Statement of key priority areas
••
Performance against priority areas (against targets set)
••
Monitoring arrangements
••
Future priorities and how they will be measured.
3.4 Information on patient survey report
Introduction
To improve the quality of services that the NHS delivers it is important to understand what patients think about
their care and treatment. One way of doing this is by asking patients who have recently used their local health
services to tell us about their experiences Northern Lincolnshire and Goole Hospitals NHS Foundation Trust took
part in the national survey for 2012.
The report shows how the Trust scored for each question in the survey, compared with the range of results from
all other Trusts that took part. It is designed to help understand the performance of individual trusts, and to
identify areas for improvement.
For each question in the survey, the individual (standardised) responses are converted into scores on a scale from
0-10. A score of 10 represents the best possible response and a score of zero the worst. The higher the score for
each question, the better the Trust is performing
Summary of performance – national patient survey
Details of the key findings from the latest national patient survey:
••
Response rate compared with prior year:
Response
rate
••
2011/12
2012/13
Comments
Trust
National
average
Trust
National
average
61%
53%
45%
51%
Areas of improvement from the prior year and deterioration
69
Annual Quality Account 2012/13
••
Top four ranking scores:
Top 4 ranking
scores
2011/12
Trust
2012/13
National
highest
National
lowest
Trust
Comments
National
highest
National
lowest
Improvement on last
year’s results.
Did you feel threatened
during stay in hospital by
other patients or visitors
9.8
10.0
9.1
9.9
10.0
9.3
Were hand- wash gels
available for patients and
visitors to use
9.7
10.0
9.2
9.8
10.0
8.8
Improvement on last
year’s results.
Not
asked
-
-
9.7
10.0
8.7
Not measured in
previous surveys.
8.7
Improvement (This
shows only 0.6
had their planned
admission date
changed)
Had the hospital
specialist been given all
necessary information
about your condition/
illness from the person
who referred you?
Was your admission date
changed by the hospital
••
9.2
9.8
8.4
9.4
10.0
(This shows only
0.2% felt threatened)
Bottom four ranking scores:
Bottom 4 ranking
scores
2011/12
2012/13
Comments
Trust
National
highest
National
lowest
Trust
National
highest
National
lowest
Did you find someone on
the hospital staff to talk
to about your worries and
fears?
6.2
7.9
4.3
5.2
7.8
4.2
Decrease from last
year’s results
Did you receive copies
of letters sent between
hospital doctors and your
family doctor (GP)
4.0
9.3
2.2
3.8
9.1
2.2
Decrease from last
year’s results
Did you see, or were you
given, any information
explaining how to
complain to the hospital
about the care you
received?
Not
asked
-
-
1.2
5.2
0.9
Not measured in
previous surveys.
During your hospital stay,
were you ever asked to
give your views on the
quality of care?
1.1
4.1
0.4
1.2
3.4
0.5
Improvement from
last year’s results.
Commentary:
This year’s report shows that the Trust performance was comparable to the other Trusts performance in all of the
questions. An action plan is currently being collated to look at how we can the improve the service we provide to
move us into the ‘best performing Trusts’. This will improve the overall patient experience. The Trust’s focus will
be to improve the results for all questions, not only those with the lowest score ensuring the Trust is constantly
moving towards becoming one of the best performing Trusts.
70
Annex
71
Annual Quality Account 2012/13
Annex 1: Statements from commissioners
Feedback from:
NHS East Riding of Yorkshire Clinical Commissioning Group
NHS North Lincolnshire Clinical Commissioning Group
NHS North East Lincolnshire Clinical Commissioning Group
Comments for publication:
Generally, this report reflects an accurate picture of the Trust in relation to quality data indicators. There are a
range of data included relating to specific quality indicators and information on positive improvement as well as
indicators that have not been met. The contextual information on the key issues of focus for the Trust in 2012-13
is representative of the issues raised by commissioning organisations during the year. Likewise, the priorities for
2013-14 that have been identified for improvement are in-line with the quality priorities of the commissioning
organisations. The Trust’s continued focus on patient experience is welcome, as well as the detailed information
provided on successful improvement schemes such as the ‘Check your Charts’ and the Early Warning system for
deteriorating patients.
Commissioners share the Trust’s concerns around the continued raised mortality rates and have been working
with the Trust on a comprehensive schedule of work to address the issue; this includes a focus on all measures
of mortality, both overall measures and in relation to specific conditions. Commissioners expect that this work
will continue to improve quality of care at the Trust, particularly for specific areas where mortality has not fallen,
where trends have not shown a marked decrease or where there have been particularly variances in mortality
rates over the year, as demonstrated in the data. Commissioners have worked with the Trust to develop a CQUIN
scheme for 2013/14 scheme which progresses further work to address the mortality issues particularly in relation
to the clinical areas where a higher than expected mortality is being reported.
Commissioners are aware that the Trust faces a challenging target to reduce its clostridium difficile rate further
next year, having failed to reach its required decrease of cases in 2012-13 and look forward to receiving the Trust
plans in respect of achieving a reduction
Broadly, the report reflects the data reported to commissioning organisations in 2012-13. It is disappointing that
further information is not included in this report regarding the actions taken following the three ‘never events’
that occurred in 2012-13 and what steps have been taken to prevent re-occurrence. The report also does not give
comprehensive analysis or narrative in all areas on the work that has been undertaken to improve services against
all data sources, including, for example learning and service changes from, patient complaints and incidents.
Commissioners feel that this is a missed opportunity to provide further assurance in relation to the work
undertaken by the Trust to improve patient experience, quality of care and ultimately reduce mortality rates.
The report shows that the Trust reviews a number of indicators for the separate hospital sites. The report does
not provide differentiated analysis where there are variances between different hospital sites and much detail on
specific actions being taken where an issue is noted at a particular site. Whilst it is appreciated that the purpose
of this report is not to over-burden with the level of detail included, commissioners will continue to work with the
Trust in 2013-14 to ensure any risks in variation or inequality of quality of service remain an area of focus for the
Trust.
The report reflects strong improvement in patient satisfaction during the year. The staff survey results are not
as strong, both in terms of response rate and some specific issues around appraisal rates and reports of bullying
and harassment. The Trust has included narrative on its focus on staff morale, therefore commissioners anticipate
receiving assurance in 2013-14 on the results of actions being undertaken by the Trust to address concerns raised
by the staff survey results.
We note that the report is based on data up to and including the end of quarter three 2012/13 and some year-end
data. Taking that into account, we confirm that to the best of our knowledge, the report is a true and accurate
reflection of the quality of care delivered by Northern Lincolnshire and Goole Hospitals and that the data and
information contained in the report is accurate.
The Clinical Commissioning Groups are looking forward to working with the Trust to improve the quality of
services available for our patients in order to continually improve patient outcomes and experience.
72
Annex 2: Statement from Healthwatch organisations
Joint statement from North Lincolnshire and East Riding of Yorkshire Healthwatch
organisations
Healthwatch North Lincolnshire and Healthwatch East Riding of Yorkshire were launched on April 1 2013. At this
stage in their development, both Healthwatch organisations are not in a position to provide a statement on the
accounts. Both Healthwatch East Riding of Yorkshire and Healthwatch North Lincolnshire would wish to start an
engagement process with the Trust so that they can play a part in the production of future Quality Accounts, to
ensure they reflects the local knowledge of both Healthwatch organisations of the services provided by the Trust,
and to ensure local priorities - as expressed by service users - are being reflected in the improvement priorities
being set by the Trust.
Statement from Healthwatch North East Lincolnshire
Unfortunately with the change over from NEL LINk to Healthwatch NEL we are not in a position to comment on
any of the Quality Accounts.
We do look forward to working with you in the future and would very much have liked to had something to
submit. We just aren't in a position to at this time. We hope you understand and look forward to hearing from you
next year when I am sure we will be better situated to comment.
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Annex 3: Statement from local Council Overview and Scrutiny Committees (OSC)
North Lincolnshire Council – Health Scrutiny Panel’s Quality Accounts comments for
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust
North Lincolnshire Council's Health Scrutiny Panel welcomes the opportunity to comment as part of Northern
Lincolnshire and Goole Hospitals NHS Foundation Trust's (NLG) Quality Account. NLAG are a key partner and
provider of local services, and members have built a valuable working relationship with Trust personnel over the
previous twelve years.
During 2012/13 the scrutiny panel has completed some work with the Trust, particularly on the local SHMI
rate, so there has been regular contact with key figures. A number of issues have also been discussed, such as
dermatology, A&E and urgent care, and other day-to-day enquiries.
The scrutiny panel shares the Trust’s concern around the continued unacceptable SHMI rates, but notes the
comprehensive work being undertaken across Northern Lincolnshire to tackle this. Despite this, the panel
continues to have some concerns that will shortly be published, along with a series of recommendations
for improvements. The scrutiny panel is encouraged by recent improvements to observations, charts and
recordkeeping across the Trust, and the successful implementation of the NEWS system. We believe this will lead
to improved care for the patient, and earlier identification of deteriorating patients.
Obviously, the panel has concerns around the higher-than-target clostridium difficile results, although members
note the improvement on the previous year’s performance, the better-than-target results on MRSA rates and the
actions taken by the Trust in seeking to improve performance on infection control.
The Trust kindly agreed that the scrutiny panel could conduct two site visits to Scunthorpe General Hospital
in 2012-13 to speak with patients and their families; one in July 2012 and one in October 2012. The visit in July
found no concerns on Disney ward, but a number of issues on Ward 28. Encouragingly, feedback to the Trust led
to immediate remedial action. The panel revisited Ward 28 in October, where all patients that members spoke
to reported that their care was good, that staff were supportive and competent, and that patients’ dignity and
safety were maintained. Again, some minor concerns were fed back to the Trust, who followed up and made the
necessary changes.
The panel notes the findings of the national inpatient survey, which is almost wholly in line with the national
average. The panel also notes the 2012 staff survey which is referenced in the Quality Account draft. Clearly,
the panel has concerns around the percentage of staff believing their role makes a difference to patients, staff
satisfaction with the quality of care they provide, and staff’s recommendations of the Trust as a place to work or
receive treatment, all of which are in the lowest quintile. However, the panel notes encouraging performance
on keeping staff free from violence, harassment, bullying or abuse. The panel would wish to see improvements
on the 30 per cent response rate for the staff survey, and would like to see the Trust take steps to encourage
completion to achieve a higher rate in 2013.
The panel is aware of acute pressure at the Trust’s A&E sites in quarter four of 2012/13, which led to the four-hour
target being missed. Whilst we acknowledge that this was far from a local phenomenon, we look forward to
receiving a copy of the local analysis of the reasons for the increased demand, and the actions taken by the Trust.
Despite these concerns, our general view is that the Trust is performing well in the majority of its services,
and reacting appropriately to the changing environment. The panel notes the recent encouraging figures
on patient satisfaction and the number of patients willing to recommend the Trust to family and friends. On
work-related issues, the chief executive and key officers provide regular, constructive updates to the panel on
ongoing and developing activities, answering members' questions in a frank and open manner. Each contact
between the Trust and the panel through the year has been positive and any queries have resulted in a swift and
comprehensive response, and we thank the Trust for this.
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North East Lincolnshire Council – Health, Housing and Wellbeing Scrutiny Panel’s Quality
Accounts comments for Northern Lincolnshire and Goole Hospitals NHS Foundation Trust
On behalf of the North East Lincolnshire Health, Housing and Wellbeing scrutiny panel, thank you for providing an
opportunity to comment on the quality account for Northern Lincolnshire and Goole Hospitals NHS Foundation
Trust.
Positive outcomes:
••
It was encouraging to see the positive patient experience survey results
••
It is good to see the actions that are going to be taken to improve the quality of healthcare as a result of clinical
audits included in the report.
Performance:
••
The risk adjusted mortality index is reducing in the Trust. The scrutiny panel has received regular updates
around this issue and are aware of the detailed action plan that is in place to reduce mortality rates
••
The graph on page eight of the report shows that the stroke risk adjusted mortality index varies quite greatly
from month-to-month
••
Palliative care still needs to improve
••
It is suggested on page 35 (decision making) of the report that an indicator around staff satisfaction be
incorporated in 2013/14. It would be useful to have some further information on this
••
It is concerning that only 55 per cent of staff would recommend the Trust as a provider of care to their family or
friends, but recognise that the Trust is taking action to improve this
••
It is concerning to see that the level of harassment is increasing in the staff survey report.
Presentation:
••
It would have been helpful to include an explanation of the reason why PARs changed to NEWS
••
The comments sections provide a helpful interpretation of the graphs
••
On page 21 of the report it would have been useful to provide a key to explain the red line
••
Gaps in the report make some sections difficult to comment on at this point in time.
The scrutiny panel would welcome Northern Lincolnshire and Goole Hospitals NHS Foundation Trust to keep
them updated on the progress being made towards the priorities in the quality account. It would also be a good
opportunity to have earlier engagement in the development of the quality account for 2013/14.
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Annual Quality Account 2012/13
East Riding of Yorkshire Council – Health Scrutiny Panel’s Quality Accounts
comments for Northern Lincolnshire and Goole Hospitals NHS Foundation Trust
East Riding of Yorkshire Council Health, Care and Wellbeing Overview and Scrutiny Sub-Committee would
like to thank the Trust for this opportunity to comment on the Northern Lincolnshire and Goole Hospitals NHS
Foundation Trust Draft Quality Accounts 2012/13.
The sub-committee welcomes the consistent approach to displaying results for 2012/13. The sub-committee
also welcomes the fact that the Trust details its performance against last year’s priorities first within the Quality
Accounts before then detailing the priorities for the coming year. This makes for a much easier read and clearly
shows how the previous year’s priorities have informed the setting of the new priorities.
Although the accounts on the whole take a consistent approach to how information is displayed by graph, some
of these were difficult to understand (particularly as some lacked an explanation to the meaning of the key and
its abbreviations). In addition, some of the data has been broken down to hospital level and the sub-committee
would have liked to have seen that for all data.
The accounts demonstrate that the Trust is not afraid to acknowledge areas where improvements are needed.
In particular, the sub-committee feel that patient safety must be improved and is disappointed to learn that
the Trust has failed to meet most of it targets within this priority. It is hoped that patient safety is given further
precedence within 2013/14 and the sub-committee are pleased to see that this is reflected in the priorities for the
forthcoming year.
The sub-committee is aware of the fact that the Trust has been identified as a persistent outlier for mortality
statistics and is, therefore, part of a review looking at quality of care and treatment. Members noted that the
Quality Accounts indicate mortality rates are falling and hope that they continue to improve over the next 12
months.
The sub-committee commend the Trust for meeting most of its targets for patient experience throughout
2012/13. It is always pleasing to hear that patient expectation is being met and that they are satisfied with the
service provided and the sub-committee hopes this continues.
Staff satisfaction is key for an organisation to achieve its desired goals and ensure customer expectations are
met. The sub-committee is encouraged that the Trust is open and honest in detailing the results of its staff survey
report and equally pleased to see that the Trust is addressing the issues/concerns raised as a result of the staff
survey.
The sub-committee welcome the priorities as set by the Trust for 2013/14. Due to the ageing population in the
East Riding, the sub-committee is particularly heartened that dementia remains a priority for 2013/14 with a
number of related sub-priorities.
The glossary made for interesting reading but members felt it needed extending to cover more issues included in
the Quality Accounts and also felt it would have also benefited from an abbreviations table.
The Trust’s participation in 38 national clinical audits was noted by the sub-committee and in particular, it is
pleasing to see that the reports of four national clinical audits and some local clinical audits has prompted the
Trust to take action to improve the quality of the healthcare it provides.
The sub-committee would like to record its thanks to the Trust for attending a number of meetings of the subcommittee during 2012/13 and looks forward to continuing the good working relationship that has been firmly
established between the Trust and the council.
Annex 4: Statement from the Trust Governors’ Service Quality Monitoring Group
Thank you for providing us with an excellent and comprehensive explanation of the Quality account. It is an
excellent report with good graphics, well presented, to allow the reader to access the information and highlights
the Trusts’ achievement and priorities during 2012/13.
The glossary section at the back of the report is a valuable tool to allow the governors to understand the detail of
the report.
We, as governors welcome the opportunity to influence the choice of quality indicators for 2013/14.
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Annex 5: Statement of directors’ responsibilities in respect of the Quality Report
The directors are required under the Health Act 2009 and the National Health Service Quality Accounts
Regulations to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality reports
(which incorporate the above legal requirements) and on the arrangements that foundation trust boards should
put in place to support the data quality for the preparation of the quality report.
In preparing the Quality Report, directors are required to take steps to satisfy themselves that:
••
The content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual
Reporting Manual 2012/13
••
The content of the Quality Report is not inconsistent with internal and external sources of information
including:
••
Board minutes and papers for the period April 2012 to March 2013
••
Papers relating to quality reported to the Board over the period April 2012 to March 2013
••
Feedback from the commissioners dated 23/05/2013
••
Feedback from governors dated 11/05/2013
••
Feedback from Local Healthwatch organsiations dated 15/05/2013
••
The Trust’s complaints report published under regulation 18 of the Local Authority Social Services and
NHS Complaints Regulations 2009, dated March 2013
••
The 2012 national patient survey
••
The 2012 national staff survey
••
The head of internal audit’s annual opinion over the trust’s control environment dated April 2013
••
CQC quality and risk profiles between April 2012 and March 2013.
••
The quality report presents a balanced picture of the NHS Foundation Trust’s performance over the period covered
••
The performance information reported in the quality report is reliable and accurate
••
There are proper internal controls over the collection and reporting of the measures of performance included in
the quality report, and these controls are subject to review to confirm that they are working effectively in practice
The data underpinning the measures of performance reported in the quality report is robust and reliable,
conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and
review; and the quality report has been prepared in accordance with Monitor’s annual reporting guidance (which
incorporates the Quality Accounts regulations) (published at www.monitor-nhsft.gov.uk/annualreportingmanual)
as well as the standards to support data quality for the preparation of the quality report (available at www.
monitor-nhsft.gov.uk/annualreportingmanual).
The directors confirm to the best of their knowledge and belief they have complied with the above requirements
in preparing the quality report.
By order of the Board
NB: sign and date in any colour ink except black
Chairman Date: 28 May 2013
Chief executive Date: 28 May 2013
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Annual Quality Account 2012/13
Annex 6: Independent auditor’s report to the Board of Governors on the Annual Quality Report
Independent Auditor’s Limited Assurance Report to the Council of Governors of
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust on the Annual
Quality Report
We have been engaged by the Council of Governors of Northern Lincolnshire and Goole Hospitals NHS
Foundation Trust to perform an independent assurance engagement in respect of Northern Lincolnshire and
Goole Hospitals 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:
1.
Number of Clostridium difficile infections; and
2.
Maximum 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 for the indicators specified above (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
••
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.
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: East Riding of Yorkshire CCG; North Lincolnshire CCG; and North East
Lincolnshire CCG
••
Feedback from Governors
••
The Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS
Complaints Regulations 2009, dated May 2013
••
The latest national patient survey dated 2012
••
The latest national staff survey dated 2012
••
Care Quality Commission quality and risk profiles dated 01/04/2012-31/03/2013
••
The Head of Internal Audit’s annual opinion over the trust’s control environment dated April 2013.
78
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 Northern
Lincolnshire and Goole Hospitals NHS Foundation Trust as a body, to assist the Council of Governors in reporting
Northern Lincolnshire and Goole Hospitals 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 Northern
Lincolnshire and Goole Hospitals 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.
••
Reading the documents.
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 specified 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 Lincolnshire and Goole NHS
Foundation Trust.
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Annual Quality Account 2012/13
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
••
The specified indicators have not been prepared in all material respects in accordance with the Criteria.
PricewaterhouseCoopers LLP Chartered Accountants
Leeds
Date: 29 May 2013
The maintenance and integrity of the Northern Lincolnshire and Goole Hospitals 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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Annex 7: Glossary
Benchmark Peer Group: Calderdale and Huddersfield NHS Foundation Trust, Chesterfield and North Derbyshire
Royal Hospital NHS Trust, Countess of Chester NHS Foundation Trust, County Durham and Darlington NHS
Foundation Trust, Doncaster and Bassetlaw Hospitals NHS Trust, North Cumbria University Hospitals NHS
Trust, North Tees and Hartlepool NHS Trust, Rotherham NHS Foundation Trust, Royal Bolton Hospital NHS
Foundation Trust, The Pennine Acute Hospitals NHS Trust, University Hospitals of Morecambe Bay NHS Trust
Cardiac bundle: The new bundle is comprised of the following HRG4 subchapters:
Procedures: Catheter 19 years and over, Pace 1 - Single chamber or Implantable Diagnostic Device, Pace 2 Dual Chamber, Percutaneous Coronary Intervention (0-2 Stents), Complex Echocardiogram (include Congenital
Transoesophageal and Fetal Echocardiography), Simple Echocardiogram, Electrocardiogram Monitoring and
stress testing, Percutaneous Coronary Intervention (0-2 stents) and Catheterisation, Minor Cardiac Procedures,
Other Non-Complex Cardiac Surgery + Catheterisation, Pace 1 - Single chamber or Implantable Diagnostic
Device and other (Catheterisation; EP; Ablation; Percutaneous Coronary Intervention), Congenital Interventions:
Other including Septostomy Embolisations Non-coronary Stents and Energy Moderated Perforation, Pacemaker
Procedure without Generator Implant (includes resiting and removal of cardiac pacemaker system), Percutaneous
Coronary Interventions with 3 or more Stents, Implantation of Cardioverter - Defibrillator only, Percutaneous
Coronary Interventions with 3 or more Stents and Catheterisation, and Intermediate Congenital Surgery.
Cardiac disorders: Non interventional acquired cardiac conditions 19 years and over, Arrhythmia or Conduction
Disorders without CC, Syncope or Collapse without CC, Actual or Suspected Myocardial Infarction, Heart Failure
or Shock without CC, Deep Vein Thrombosis, Syncope or Collapse with CC, Heart Failure or Shock with CC,
Hypertension without CC, Arrhythmia or Conduction Disorders with CC, Cardiac Valve Disorders, Hypertension
with CC, Endocarditis, Cardiac Arrest, and Non-Interventional Congenital Cardiac Conditions.
Commissioning for Quality and Innovation Framework (CQUIN): The CQUIN payment framework enables
commissioners to reward excellence, by linking a proportion of English healthcare providers' income to the
achievement of local quality improvement goals. Since the first year of the CQUIN framework (2009/10), many
CQUIN schemes have been developed and agreed. This is a developmental process for everyone and you are
encouraged to share your schemes (and any supporting information on the process you used) to meet the
requirement for transparency and support improvement in schemes over time.
Common cause variation: an inherent part of the process, stable and “in control”. We can make predictions
about the future behaviour of the process within limits. When a system is stable, displaying only common cause
variation, only a change in the system will have an impact.
Complaints: The NHS Complaints Regulations (England) 2009 require that an offer to discuss the complaint
with the complainant is made on receipt of all complaints; the discussion to include the response period (the
period within which the investigation is likely to be completed and when the response is likely to be sent to the
complainant). The requirement is to investigate the complaint in an appropriate manner, to resolve it speedily
and efficiently and to keep the complainant informed as to progress. The response should be within 6 months or
a longer period if agreed with the complainant before the expiry of that period.
The Complaints Regulations permit extensions to the agreed timescale where this becomes necessary
and in agreement with the complainant. The Trust (as outlined within the Policy for the Management of
Complaints) expects that any delay to the agreed response time is communicated to the complainant, the reasons
explained and an extension agreed.
In respect of monitoring, the Regulations require (amongst other points) that the Trust maintain a record of the
response periods and any amendment of that period and whether the response was sent to the complainant
within the period or any amendment of that period.
Key definitions to interpret complaints data:
••
NEW: The number of new complaints received in a month regardless of whether or not they were resolved
within that month.
••
CLOSED: The number of complaints that were resolved within a month regardless of whether they were
received within the month or resolved within agreed timescale.
••
NET OPEN: The total number of complaints currently open; includes new, unresolved from previous month(s)
and complaints open ‘on hold’.
••
RE-OPENED: Complaints that have been resolved which for any number of reasons require further review.
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Annual Quality Account 2012/13
Control limits: indicate the range of plausible variation within a process. They provide an additional tool for
detecting special cause variation. A stable process will operate within the range set by the upper and lower
control limits which are determined mathematically (three standard deviations above and below the mean).
The upper control limit is displayed in blue throughout this report. The lower control limit is displayed in teal
throughout this report.
Crude mortality rate: The crude mortality rate is based on actual numbers. Unlike the HSMR which features
adjustment based on population demographics and related mortality expectations.
The local benchmarking rate for crude mortality is adjusted quarterly. The latest adjustment reflects January 2010 data.
Fall: A sudden, unintended, uncontrolled downward displacement of a patient’s body to the ground or other
object. This includes situations where a patient falls while being assisted by another person, but excludes falls
resulting from a purposeful action or violent blow.
Unpreventable fall: Impossible to avoid the fall(s) from happening. Recognizes that some of these events
are not always avoidable, given the complexity of healthcare; therefore, the presence of an event on the list is not
evidence of a systems failure or a lack of due care.
Preventable fall: The fall(s) could have been avoided. Describes an event that could have been anticipated
and prepared for, but that occurs because of an error or other system failure.
Harm:
••
Catastrophic harm: Any patient safety incident that directly resulted in the death of one or more persons
receiving NHS funded care.
••
Severe harm: Any patient safety incident that appears to have resulted in permanent harm to one or more
persons receiving NHS-funded care.
••
Moderate harm: Any patient safety incident that resulted in a moderate increase in treatment and which
caused significant but not permanent harm, to one or more persons receiving NHS-funded care. Locally
defined as extending stay or care requirements by more than 15 days; Short-term harm requiring further
treatment or procedure extending stay or care requirements by eight - 15 days
••
Low harm: Any patient safety incident that required extra observation or minor treatment and caused minimal
harm, to one or more persons receiving NHS-funded care. Locally defined as requiring observation or minor
treatment, with an extended stay or care requirement ranging from one to seven days
••
None/ ’Near Miss’ (Harm): No obvious harm/injury, Minimal impact/no service disruption
Hospital Standardised Mortality Rate (HSMR): The HSMR is a method of comparing mortality levels in different
years, or between different hospitals. The ratio is of observed to expected deaths, multiplied conventionally by
100. Thus, if mortality levels are higher in the population being studied than would be expected, the HSMR will
be greater than 100. This methodology allows comparison between outcomes achieved in different trusts, and
facilitates benchmarking.
Live dataset: A live dataset is one which is continuously added to over time. This means that incidents that are
reported relating to a particular point in time can be added whenever they are resolved and arrive for data entry.
This means that historic figures can change over time, reflected in subsequent reports.
Mortality by diagnosis group: These comparisons can be and are made for a large number of conditions and
operations. The three chosen are common conditions affecting many people.
Some people with acute myocardial infarction (heart attack), fractured neck of femur (broken hip) and stroke
die before they can be admitted to hospital. However, there are variations in hospital death rates among those
who survive long enough to be admitted. Some of these deaths may be potentially preventable through faster
ambulance response times and effective early treatments, so these figures may be considered as indicative of the
overall outcome of care in the Trust.
Patient experience: This Trust has set the goal of being the hospital of choice for our local patients. Being the
hospital of choice is a far different thing than being the hospital of convenience, proximity or default. We measure
patient experience using methodologies employed by the NHS National Patient Experience Survey against two
key indicators to help us determine that our hospitals are the ones our patients would choose if the practical
factors were removed.
82
The Trust uses The Menu Card Survey which asks five questions relating to patient experience and is attached to
inpatients’ menu cards. It measures the patients’ experience in real time. The questions asked are all derived
from questions that feature in all National Patient Surveys.
The scores depicted in the graphs reflect an absolute figure generated by this methodology (in short – high score
is good, 100 per cent would be the maximum achievable score).
Patient medication incident: A medication incident is any preventable medication related event that could, or
did, lead to patient harm, loss or damage.
All medication incidents are recorded on the DATIX Risk Management Software System, which holds a “live” data
set which means that monthly figures can change if there are delays in submission of incident report forms by
clinical areas. To minimise the amount of fluctuation, data is reported two months in arrears.
Pressure ulcer: Definition of avoidable and unavoidable pressure ulcer
The Department of Health (DH) has been asked to clarify what an avoidable pressure ulcer is in regards the nurse
sensitive outcome indicators. The DH researched the availability of definitions, finding that there are a limited
number of definitions in existence to draw from.
The Wound, Ostomy and Continence Nurses Society of the US have produced a position paper which points to a
clear definition of “avoidable” pressure ulcer (WOCNS) March 2009. However, the DH are using a modified version
of the Avoidable d Unavoidable pressure ulcers definitions from the Centre for Medicare and Medicaide (CMS)
2004, to keep with the UK policy Terminology.
The modified definitions are:
Avoidable pressure ulcer:
“Avoidable” means that the person receiving care developed a pressure ulcer and the provider of care did not do
ONE of the following:
••
Evaluate the person’s clinical condition and pressure ulcer risk factors
••
Plan and implement interventions that are consistent with the persons needs and goals and recognised
standards of practice within the Trust
••
Monitor and evaluate the impact of the interventions
••
Revised the interventions as appropriate
Unavoidable pressure ulcer:
“Unavoidable” means that the person receiving care developed a pressure ulcer even though the provider of the
care had done ALL of the following
••
Evaluated the persons clinical condition and pressure ulcer risk factors
••
Planned and implemented interventions that are consistent with the persons needs and goals and recognised
standards of practice within the Trust
••
Monitored and evaluated the impact of the interventions
••
Revised the interventions as appropriate
••
The individual person refused to adhere to prevention strategies in spite of education of the consequences of
non-adherence and this was documented.
Pressure ulcer gradings from the European Pressure Ulcer Advisory Panel (EPUAP):
Category/Grade 1: Non-blanchable redness of intact skin
Intact skin with non-blanchable erythema of a localized area usually over a bony prominence. Discoloration of
the skin, warmth, edema, hardness or pain may also be present. Darkly pigmented skin may not have visible
blanching.
Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.
Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons.
Category/Grade 2: Partial thickness skin loss or blister
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.
May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister.
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Annual Quality Account 2012/13
Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. This category/stage
should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or
excoriation.
Category/Grade 3: Full thickness skin loss (fat visible)
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some
slough may be present. May include undermining and tunnelling.
Further description: The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge
of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers
can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure
ulcers. Bone/tendon is not visible or directly palpable.
Category/Grade 4: Full thickness tissue loss (muscle/bone visible)
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include
undermining and tunnelling.
Further description: The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of
the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow.
Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint
capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.
Readmission rate (RA): This measure shows the percentage of patients who were readmitted to hospital as an
emergency within one month of being discharged. It can serve as an indicator of the quality of care provided
and post-discharge follow up. A low readmission rate is an indicator of the quality of care in that it reflects a
healthy care balance. Where rates are low, patients are not having to come back to the Trust for care of the same
complaint. Conversely, a high readmission rate potentially signals that an organisation is releasing patients home
too soon or otherwise not addressing all elements of their clinical condition.
Relative risk (RR): The relative risk indicator is calculated by taking the actual number of inpatients and dividing
them by the expected number of inpatients expressed as a percentage. A figure less than 100 represents better
than expected performance (highlighted in green).
Sigma: A sigma value is a description of how far a sample or point of data is away from its mean, expressed in
standard deviations usually with the Greek letter σ or lower case s. A data point with a higher sigma value will
have a higher standard deviation, meaning it is further away from the mean.
Special cause variation: The pattern of variation is due to irregular or unnatural causes. Unexpected or
unplanned events (such as extreme weather recently experienced) can result in special cause variation. Systems
which display special cause variation are said to be unstable and unpredictable. When systems display special
cause variation, the process needs sorting out to stabilise it. This report includes two types of special cause
variation, trends and outliers. If a trend, the process has changed in some way and we need to understand and
adopt if the change is beneficial or act if the change is a deterioration. The outlier is a one-off condition which
should not result in a process change. These must be understood and dealt with on their own (ie response to a
major incident).
Standard deviation: Standard deviation is a widely used measurement of variability or diversity used in statistics
and probability theory. It shows how much variation or "dispersion" there is from the "average" (mean, or
expected/budgeted value). A low standard deviation indicates that the data points tend to be very close to the
mean, whereas high standard deviation indicates that the data are spread out over a large range of values.
Valid Data Set: A minimum of 21 data points is required for a valid data set using the SPC methodology.
Identifying Special Cause Variation
••
Seven or more points on the same side of a centre line
••
Consecutive points going alternately up or down 13 times
••
Seven successive points all going up or down
••
A point widely different from all the others (such as a point falling outside control limits)
••
Points following a cyclical pattern.
X (centre line): The SPC charts in this report display the centre line mean in red which is used in identifying types
of variation.
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Annex 8: Mandatory performance indicator definitions
Quality indicator guidance: All foundation trusts are required by the NHS Operating Framework 2012/13
to measure performance against quality, resources and reform. The majority of the mandated performance
indicators in the quality report have been defined by the Department of Health in its Technical Guidance for
the 2012/13 Operating Framework and/or in its NHS Outcomes Framework 2012/13: Technical Appendix. Extracts of
those definitions are attached below and can be assumed to come from the Department of Health’s published
guidance unless otherwise indicated.
Acute NHS Foundation Trusts
Clostridium difficile
Detailed descriptor
Number of clostridium difficile infections, as defined below, for patients aged two or more on the date the
specimen was taken.
Data definition A clostridium difficile infection is defined as a case where the patient shows clinical symptoms
of clostridium difficile infection, and using the local Trust clostridium difficile infections diagnostic algorithm (in
line with DH guidance) is assessed as a positive case. Positive diagnosis on the same patient more than 28 days
apart should be reported as separate infections, irrespective of the number of specimens taken in the intervening
period, or where they were taken.
In constructing the clostridium difficile objectives use was made of rates based both on population sizes and
numbers of occupied bed days. Sources and definitions used are:
For acute trusts: The sum of episode durations for episodes finishing in 2010/11 where the patient was aged two
or over at the end of the episode from Hospital Episode Statistics (HES).
Basis for accountability
Acute provider trusts are accountable for all clostridium difficile infection cases for which the trust is deemed
responsible. This is defined as a case where the sample was taken on the fourth day or later of an admission to
that trust (where the day of admission is day one).
To illustrate:
••
Admission day
••
Admission day + 1
••
Admission day + 2
••
Admission day + 3 -specimens taken on this day or later are trust apportioned
Accountability
The approach used to calculate the clostridium difficile objectives requires organisations with higher baseline
rates (acute trusts and primary care organisations) to make the greatest improvements in order to reduce
variation in performance between organisations. It also seeks to maintain standards in the best performing
organisations.
Appropriate objective figures have been calculated centrally for each PCO and each acute trust based on a
formula which, if the objectives are met, will collectively deliver a further national reduction in cases of 26 per
cent for acute trusts and 18 per cent for PCOs whilst also reducing the variation in population and bed day rates
between organisations.
Timeframe/baseline
The baseline period is the 12 months October 2010 to September 2011. This means that objectives have been set
according to performance in this period.
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Annual Quality Account 2012/13
Maximum waiting time of 62 days from urgent GP referral to first
treatment for all cancers
Detailed descriptor
PHQ03: Percentage of patients receiving first definitive treatment for cancer within 62 days of an urgent GP
referral for suspected cancer.
Data definition
All cancer two month urgent referral to treatment wait
Denominator: Total number of patients receiving first definitive treatment for cancer following an urgent GP
(GDP or GMP) referral for suspected cancer within a given period for all cancers (ICD-10 C00 to C97 and D05)
Numerator: Number of patients receiving first definitive treatment for cancer within 62 days following an urgent
GP (GDP or GMP) referral for suspected cancer within a given period for all cancers (ICD-10 C00 to C97 and D05)
Accountability
Performance is to be sustained at or above the published operational standard.
Details of current operational standards are available at: http://www.dh.gov.uk/en/Publicationsandstatistics/
Lettersandcirculars/Dearcolleagueletters/DH_103436
Emergency readmissions within 28 days of discharge from hospital
Indicator description
Emergency readmissions within 28 days of discharge from hospital.
Indicator construction
Percentage of emergency admissions to any hospital in England occurring within 28 days of the last, previous
discharge from hospital.
Numerator: The number of finished and unfinished continuous inpatient spells that are emergency admissions
within 0-27 days (inclusive) of the last, previous discharge from hospital (see denominator), including those
where the patient dies, but excluding the following: those with a main speciality upon readmission coded
under obstetric; and those where the readmitting spell has a diagnosis of cancer (other than benign or in situ) or
chemotherapy for cancer coded anywhere in the spell.
Denominator: The number of finished continuous inpatient spells within selected medical and surgical
specialities, with a discharge date up to March 31 within the year of analysis. Day cases, spells with a discharge
coded as death, maternity spells (based on specialty, episode type, diagnosis), and those with mention of a
diagnosis of cancer or chemotherapy for cancer anywhere in the spell are excluded. Patients with mention of a
diagnosis of cancer or chemotherapy for cancer anywhere in the 365 days prior to admission are excluded.
Indicator format: Standard percentage.
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All NHS Foundation Trusts
Patient safety incidents reported
Indicator description
Patient safety incidents reported to the National Reporting and Learning Service (NRLS).
Indicator construction
The number of incidents as described above.
A patient safety incident (PSI) is defined as ‘any unintended or unexpected incident(s) that could or did lead to
harm for one of more person(s) receiving NHS funded healthcare’.
Indicator format: Whole number.
Safety incidents involving severe harm or death
Indicator description
Patient safety incidents reported to the National Reporting and Learning Service (NRLS), where degree of harm is
recorded as ‘severe harm’ or ‘death’, as a percentage of all patient safety incidents reported.
Indicator construction
Numerator: The number of patient safety incidents recorded as causing severe harm /death as described above.
The ‘degree of harm’ for PSIs is defined as follows;
‘severe’ – the patient has been permanently harmed as a result of the PSI, and
‘death’ – the PSI has resulted in the death of the patient.
Denominator: The number of patient safety incidents reported to the National Reporting and Learning Service
(NRLS).
Indicator format: Standard percentage.
i.
Cancer referral to treatment period start date is the date the acute provider receives an urgent (two week wait priority)
referral for suspected cancer from a GP and treatment start date is the date first definitive treatment commences if
the patient is subsequently diagnosed. For further detail refer to technical guidance at http://www.dh.gov.uk/en/
Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131880 PHQ03: Percentage of patients
receiving first definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer.
ii.
This definition is adapted from the definition for the 30 days readmissions indicator in the NHS Outcomes Framework
2012/13: Technical Appendix.
iii.
Monitor has the removed the requirement to report this as a rate per 100,000 population.
iv.
Monitor has replaced the requirement to report this as a rate per 100,000 population with the requirement to report
such incidents as a percentage of all PSIs reported by the trust.
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