Contents
Part 1
About the Quality Account
5
About the Nottingham NHS Treatment Centre
6
Statement from the General Manager
7
Engagement
8
Part 2
Achievement against Quality Improvement Priorities for 2012/13
11
Review of Quality Performance for 2012/13
18
Quality Improvement Priorities for 2013/14
28
Mandatory Statements
30
Part 3
Clinical Unit Quality Accounts
39
Part 4
Statement from the Patient & Public Engagement Committee
73
Statement from Nottingham City Clinical Commissioning Group
74
Statement from the Joint Nottinghamshire Health Scrutiny Committee
75
Jargon Buster
76
About the Quality Account
The National Health Service (Quality Account) Regulations 2010 require that all providers of
healthcare services to NHS patients publish an annual report about the quality of their
services; this report is called a Quality Account. The primary purpose of a Quality Account is
to enhance organisational accountability to the public, to engage Boards and leaders of
organisations in fully understanding the importance of quality across all of the healthcare
services they provide and promote continuous improvements on behalf of their patients.
A Quality Account must include:
x
$VWDWHPHQWVXPPDULVLQJWKH5HJLVWHUHG0DQDJHU¶VYLHZRITXDOLW\RIVHUYLFHVSURYLGHG
to NHS patients;
x
A review of the quality of services provided over the last finanical year (2012/13);
x
Quality priorities for the coming financial year (2013/14)
The Nottingham NHS Treatment Centre is extremely proud to present its Quality Account for
2012/13. Our Clinical Units have worked very hard to produce their own quality accounts
that represent how motivated and driven they are to improve services for their patients. We
have also worked closely with the Executive Board and Clinical Governance & Risk
Management Committee to produce a Quality Account that provides our patients and the
general public with information that demonstrates our commitment to quality as the first and
foremost priority in our organisation; and provides the reader with a comprehensive insight
into who we are and what we do.
5
About the Nottingham NHS
Treatment Centre
The Nottingham NHS Treatment Centre belongs to a group of companies owned by Circle,
and is the largest Independent Sector Treatment Centre (ISTC) in Europe. Circle is an
employee co-owned partnership with a social mission to make healthcare simpler, better
and smarter value for patients. Circle is co-founded, co-run, and co-owned by clinicians
and healthcare professionals. Because the clinicians and healthcare professionals who
work for Circle have a sense of ownership for their work, they are empowered to put
patients first in everything that they do. &LUFOH¶Vapproach is based on the premise that
clinicians are best placed to decide how to deliver the best care for patients and Our Credo
FRPPLWVXVWREHLQJµDERYHDOOWKHDJHQWVRIRXUSDWLHQWV¶
The Services delivered at the Nottingham NHS Treatment Centre, as with other Circle
Hospitals are divided into separate business units, named Clinical Units. Each Clinical Unit
is led by a doctor, nurse and administrator and the Unit has the freedom and authority to
take decisions that impact upon patient care. They are also responsible for managing their
own budgets. In this way, power is devolved to the frontline and decisions are taken as
close as possible to patients. Our success as a company does not lie in a small group of
expert managers at the top of the company but in a large community of expert innovators at
the grass-roots. In this way, we maximise our effectiveness and harness the collective
wisdom of a large group of people to offer the best possible solutions for our patients.
Services provided at the Nottingham NHS Treatment Centre include: Day Case
Surgery, Cardiology (non-invasive), Dermatology, Diagnostic Services, Digestive
Diseases, Endocrinology, Endoscopy, Gynaecology, Orthopaedics, Respiratory,
Rheumatology, Urology and Vascular Services.
The Treatment Centre comprises of 71 Consultation rooms, 4 Endoscopy suites, 5 Day
Case surgery theatres, Computerised Tomography (CT), Ultrasound (US), 3
Colposcopy/Hysteroscopy rooms, 3 Dermatology skin surgery theatres, Light Therapy,
Magnetic Resonance Imaging (MRI) and X-Ray digital imaging.
6
Statement
from the
the General
General Manager
Manager
S
tatement from
2012/13 has been an unusual year for the Nottingham NHS Treatment Centre, approaching the
final year of the 5 year contract. This resulted in uncertainty as to whether Circle would deliver the
services after 28 July 2013, leaving many staff unsettled about their future. However, even with
WKLVEDFNGURSZHDUHH[FHSWLRQDOO\SURXGWKDWWKLV\HDU¶V4XDOLW\$FFRXQWKLJKOLJKWVthat the
Clinical Unit Teams have continued to deliver high quality care, demonstrated through efficient and
effective clinical outcomes with the level of care remaining exceptionally high. This is extremely
important at a time when the Francis Report (2013) highlights the requirement for front line staff to
take responsibility for the care they and their colleagues provide to all patients and carers.
Our staff have continued to embrace the Circle Operating System bringing our Credo to life. Each
CliniFDO8QLWKDVUHYLHZHGODVW\HDU¶s annual quality data and set priorities for the coming year that
matter to them and their patients. These priorities are identified in the individual Quality Accounts
which have been shared across all the teams, with the Executive Board giving their support for
their delivery.
We are delighted that our Patient & Public Engagement Group has continued to actively support
and work within the Clinical Units to ensure that patient feedback and views are heard and acted
upon. Members have kindly attended Clinical Unit partnership events and listened to what our
staff say regarding service improvement whilst providing refreshing and valuable challenge to each
of the teams.
We have also taken the opportunity to reflect the CRPPLVVLRQHU¶VUHTXLUHPHQWVERWKLQWHUPVRI
patient safety and quality and cost effective care. Our response to delivering the Commissioner
requirements is reflected in our over-arching Treatment Centre priorities and we have articulated
our vision for the future delivery of services within our successful contract renewal bid. This
introduces a new way of delivering services across the whole healthcare economy through an
integrated care approach which in itself will benefit patients as well as present some challenges.
In developing our approach for agreeing both local and strategic priorities we have once again
consulted with patients and carers, our Patient & Public Engagement Group, our front-line staff
and other stakeholders. The Executive Board have reviewed the Quality Account and we can
confirm that the content is a balanced view of the quality of services we provide and that, to the
best of our knowledge, the information in this document is accurate.
Rachael Magnani (General Manager)
Rachael Magnani (General Manager)
Roddy Nash (Clinical Chair)
Roddy Nash (Clinical Chair)
7
Engagement
During the process of preparing our Quality Account for 2012/13, we felt that it was really
important to have an integrated approach whereby no one view was more important than
another. We consulted with our staff at partnership events, engaged patient & public views,
scanned the NHS landscape and discussed quality priorities with our Commissioners at our
quality review meetings, General Practioners via our Primary Care Manager and other
stakeholders during the course of the financial year.
As a company, we also wanted to ensure we had one voice, one vision , one team.
Individual Quality Accounts were developed by each Clinical Unit but also collective views
of the Board and its sub-committees were sought. We have use our quality priorities to
influence the corporate quality objectives and have undertaken streams of work (such as
µ6WRSWKH/LQH¶DQG&RPSDVVLRQLQ&DUHDFURVVDOORIWKH&LUFOHKRVSLWDOV and intend to
continue this going forward.
Our approach was multi-dimensional, we wanted to takHDVQDSVKRWRIWKHZKROH\HDUV¶
data and effectively consider all information avilable to us. We wanted our priorities to be
holistic so that our quality priorities could build on the existing excellent work that has been
done in the previous financial year.
8
Achievement against Quality
Improvement Priorities for 2012/13
Quality Domain
Best Patient
Experience
Our Quality Priorities for 2012/13
Survey 10% of patients that visit the
facility
Achieve an NPS score of 75%
Achieved
x
Continue to improve wait times
for patients visiting outpatient
clinics
x
75% of patients should wait no longer
than 30 minutes from their appointment
time to first contact with a clinician
Achieved
Compassionate Care
x
Improved skill and competency of
workforce and identification of named
champions to lead on compassionate
care
Development of care & compassion
assessment tool, implementation of pilot
and roll out
Provision of training to 100% of frontline
gateways and front of house
Achieved
1XPEHURIRFFDVLRQVWKDWµ6WRSWKH/LQH¶
has been activated
Number of improvements identified
Number of improvements implemented
with success measures
25% increase in incident reporting
Achieved
x
x
Improve patient safety through
Stop the Line and
Shine the Light innovation
projects
x
x
x
x
Most Engaged
Staff
Status
Include net promoter score as
part of our rapid cycle feedback
process
x
Best Clinical
Outcome
Success Measures for 2012/13
Provide the highest quality
Endoscopy Service for our
patients.
x
During 2012-13 achieve the Joint
Advisory Group (JAG) accreditation in
Endoscopy
Achieved
Drive quality improvements in
skin cancer services as part of
the Cancer Peer Review
Program
x
Achieve 85% of measures identified in
the Peer Review Assessment tool
Partially
Achieved
Implementation of a nurse
leadership and development
programme
x
Launch of Circle Nottingham
Preceptorship Programme
Achieved
Best Patient Experience
Include net promoter score as part of our rapid cycle feedback process
In July 2012 we introduced Net Promoter Score to our rapid feedback cycle in order to align with
the NHS. We amended the feedback card we use and updated the database that captures this
information. Internally we set ourselves a target of 15% response rate which was slightly above
the national requirement of 10%. We also wanted to achieve a net promoter score which would be
in the top quartile compared with other NHS organisations. We therefore reviewed the national
data and having undertaken a pilot in July, we set ourselves a realistic target of 75%.
Although we have not collected a full year of data, we have over the last 9 months achieved a 16%
response rate which equates to 29,349 patients responding. Overall, we achieved an average Net
Promoter Score of 80% (17,165 promoters, 3,550 passives and 291 detractors). Next year we
intend to improve the response rate to 20% and in order to remain in the top quartile for Net
Promoter Score, we therefore set a target of 80%.
11
Achievement against Quality
Improvement Priorities for 2012/13
78%
65%
67%
82%
81%
80%
78%
68%
68%
69%
81%
79%
70%
71%
82%
69%
82%
70%
NTC
NHS East Midlands
Continue to improve wait times for patients visiting outpatient clinics
On reviewing patient feedback, a number of Clinical Units identified wait times as a recurring
theme. We established that the tipping point for dissatisfaction for patients was waiting longer than
30 minutes and as such we agreed that 75% would be seen at the appointment time allocated or
within the 30 minutes. Two Clinical Units who had experienced the highest level of feedback
regarding wait times undertook a detailed audit and shared their results so that all Clinical Units
could learn and improve practice.
Gateway I (Digestive Diseases & Urology)
Week 1 = 92% patients were seen on time
Week 3 = 83% patients were seen on time
Week 2 = 82% patients were seen on time
Week 4 = 54% patients were seen on time
The audit demonstrated that patients were arriving up to an hour before their appointment time,
clinicians were arriving late for their clinics due to other clinical commitments, clinics were
overbooked primarily due to 2 week wait cancer pathway patients, and the average consultation
slot allocated was shorter than required. In responding to this audit data, the Unit reviewed and
changed the appointment slots for new and follow up patients, doctors¶ arrival times were
addressed, and letters to patients were adapted to request that they arrive 15 minutes before their
appointment time.
Gateway F (Gynaecology)
Clinic 1 = 44% patients were seen on time
Clinic 3 = 74% patients were seen on time
Clinic 5 = 36% patients were seen on time
Clinic 7 = 64% patients were seen on time
Clinic 2 = 50% patients were seen on time
Clinic 4 = 44% patients were seen on time
Clinic 6 = 72% patients were seen on time
12
Achievement against Quality
Improvement Priorities for 2012/13
The audit demonstrated that patients were arriving on average 35 minutes early, clinics were
overbooked, and patients were with the doctor for 25 minutes as opposed to the allocated
timescales of 10 minutes for follow up patients and 25 minutes for new patients. The major delay
was the requirement for patients to have multiple tests before they saw the doctor. In response to
the audit data, the Unit reviewed its appointment scheduling for new and follow up patients and
reduced the amount of overbooking. Patients are also now provided with an information leaflet
explaining the service and that multiple tests may be required so that they may be in the unit for a
significant amount of time.
Patient feedback data is reviewed monthly by each Clinical Unit to identify key themes associated
with waiting times; problem areas are targeted and solutions identified. Following on from these
audits each Clinical Unit has taken the recommendations on board by reviewing and adjusting their
clinic scheduling structure to allow for patient individual needs. Improvements to communication
have been implemented and we now have a live feed to the waiting area television screens
informing patients of their clinic status and staff verbally update patients as they arrive.
Compassionate Care
In February we held our Patient 1st awareness week, part of our Compassion in
Care initiative. In the main reception area, Patient 1st Champions were out and
about meeting staff, patients, and members of the public to help promote our
message. Our Compassion in Care Framework was developed in partnership with
front line staff and members of our Patients and Public Engagement group. The
framework was designed specifically to meet the needs of patients attending the Treatment Centre
for outpatient appointments and Day Case procedures. The four domains within the framework,
Look at Me, Listen to Me, Keep Me Safe and Empower Me, cover the essential elements that are
vital in providing compassionate care.
Throughout the week, 66 champions participated in a promotional event where they spoke to
patients and carers about the importance of providing compassionate care.
I put my
I put my
I put my
´EHFDXVHLWLVVRLPSRUWDQWWKDWWKH\
feel at ease and feel safe. I enjoy
KHOSLQJSDWLHQWVµ
Tracey
Healthcare Assistant
´E\HQVXULQJDFOHDUXQGHUVWDQGLQJ
of their medicine in a friendly and
SURIHVVLRQDOPDQQHUµ
Susan
Chief Pharmacy Technician
13
´DV,DPDOZD\VWKHUHIRUP\
patients, at any time they
QHHGPHµ
Martin Powell
Consultant Gynaecologist
Achievement against Quality
Improvement Priorities for 2012/13
During the week we asked our patients, visitors and staff to nominate an outstanding member of
our staff or team who had provided empathetic care. Names of nominated staff members and the
reason for nomination were showcased to all. Staff and Teams who received outstanding praise
for providing compassionate care received a certificate of recognition. We received 685
nominations during the course of that week. Putting Patients 1st - Staff at all levels across the
organisation provided feedback detailing why or how they put patients first, which were displayed
as posters during the Patient 1st week and really brought to life the reasons why they come to work
in the Treatment Centre.
Awareness sessions were held for all staff informing them of the Compassion in Care Framework
which helped to promote the importance of seeing µthe person in the SDWLHQW¶and ensure we
continue to deliver compassionate care and put our patients first, all of the time.
Best Clinical Outcome
Improve patient safety through Stop the Line and Shine the Light innovation projects
During the month of October 2012 we ran a patient safety campaign cDOOHGµ6WRSWKH/LQH¶WR
improve patient safety across all departments. µ6WRSWKH/LQH¶LVDWHUPERUURZHGIURPWKH
manufacturing industry, where every worker on the shop floor has the power to bring the whole
production line to a halt if they sense any risk to safety. Circle partners adopted the methodology
to make it work in a hospital setting. We had 25 staff champions who supported their colleagues in
the first few months of implementation resulting in 11 occasions where 'Stop the Line' was initiated.
During the campaign we asked our patients if they thought this campaign would make them feel
safer. Over 500 patients 'liked' this campaign.
This concept works by
letting all staff know
they have the power
and responsibility to
µ6WRSWKH/LQH¶RQDQ\
activity which they
think could cause
harm to a person.
6WDIIZKRµ6WRSWKH
/LQH¶DUHQRWRQO\
supported but
celebrated by their
colleagues. By taking
decisive action when a
'Stop the Line' is
called means
solutions are put in place promptly. All safety events that have the potential to cause serious harm
are escalated to the senior team within one hour and within 48 hours the clinical teams meet and
discuss the issues and consider immediate preventative actions. The Nottingham Clinical
Governance and Risk Management Committee (CGRM) receive the learning which is cascaded to
14
Achievement against Quality
Improvement Priorities for 2012/13
all Clinical Units. Through the company Integrated Governance Committee (IGC) we share
learning across our sites.
Below is a snapshot of what has been achieved so far (for more detail please refer to the Quality
Review Section)
x Improvements in the referral review process in Digestive Disease has assisted in the reduction
of patients attending either an unsuitable service or Consultant for their condition
x Implementation of staff training, monthly auditing and a change of documentation has improved
record keeping in the management of Controlled Drugs in the Day Case Unit
x Implementation of emergency drills have been established to ensure delays in obtaining blood
in an emergency situation does not occur
x Simplification of the swab count procedure with the removal of process duplication and
improved communication for all staff (including students)
x Changes to the storage, prescribing and dispensing of bowel preparation medicines to ensure
patients receive the correct drug before their procedure
We achieved an overall increase in incident reporting, being 11% up on the previous year. We
were hopeful to achieve an increase of 25%, but part way through the year (September) we
transferred to a new risk management system resulting in a noticeable dip in the incidents
reported. We assume this was due to our staff being unfamiliar with the newer version.
Drive quality improvements in skin cancer services as part of the Cancer Peer
Review Program
The National Cancer Peer Review Programme is an integral part of the NHS Cancer Reform
Strategy and provides assurance that cancer services are being delivered to the highest quality
and in the safest way. It focuses on quality improvement through the monitoring of a range of
quality standards. The National Cancer Peer Review Programme is an annual self-assessment
supported by a targeted visit by the Cancer Peer Review Team which consists of a clinician, a
specialist nurse and a lay person, who review evidence to confirm the self-assessment results.
The Cancer Peer Review is concerned not only with the review of an organisations compliance
against the set standards but also aims to ascertain whether the service has a robust quality
framework including a supportive and learning focussed environment for staff, provision of safe
services, effective care, and excellent patient and carer experience.
We set an internal target of 85% compliance with the standards. Unfortunately, this was not
achieved to this level, however a number of improvement suggestions were made by the Cancer
Peer Review Team along with some recommendations.
What we have done so far x
Implementing weekly rather than fortnightly Multi-Disciplinary Team (MDT) reviews to account
for the number of patients being referred to the service. The core members of the MDT
15
Achievement against Quality
Improvement Priorities for 2012/13
undertake a review of all skin cancer cases and decide on the best treatment plan for the
patient.
x
Patients requiring complex procedures for certain non-malignant skin cancers (Basal Cell
Carcinoma - BCC) are now discussed at the MDT.
x
Attendance of core members to the MDT meeting has improved since the implementation of
video conferencing for those clinicians based at other hospitals.
x
Reviewed the number of surgeons undertaking nodal dissections to ensure competencies are
maintained.
The team were commended for their recruitment into clinical trials and it was also recognised that
there were excellent links with the Young Adults MDT. It was noted that there were a high volume
of patients seen by the Dermatology Team and that the Treatment Centre ensures all are seen
within a timely manner. The BCC referrals were being seen within three weeks which was ahead
of the National Target.
Provide the highest quality Endoscopy Service for our patients
The Nottingham NHS Treatment Centre has successfully achieved JAG Accreditation (Joint
Advisory Group on Gastrointestinal Endoscopy). We are one of a handful of Independent Sector
Endoscopy units that have passed JAG Accreditation to date (10%). The Endoscopy Global Scale
(GRS) is a national quality improvement system for Endoscopy units designed to provide a
framework for continuous improvement. Achieving JAG Accreditation demonstrates that we
provide the highest level of care and enables us to participate in the National Bowel Screening
Programme.
The four key standards focus on: Clinical Quality, Patient Experience, Training and
Workforce. These standards are broken down further with over 300 elements, each one requiring
the achievement of a level A or B statement.
In order to achieve accreditation we spent a year reviewing policies, guidelines and standard
operating procedures. We invested approximately £70,000 in redesigning the layout of the unit to
optimise space and improve patient through-put. We also significantly improved patient privacy
and dignity, and eliminated any possibility of mixed sex accommodation breaches. We reevaluated the units staffing model and adjusted it to ensure that lists were run effectively,
implemented a new procedure reporting system, undertook numerous audits to assure ourselves
that our clinical outcomes were excellent, and undertook patient and staff surveys to ensure that
WKHFKDQJHVZHPDGHPHWHYHU\RQH¶VH[SHFWDWLRQV
The feedback from the assessor on the day was that the patient flow on the unit was exceptional,
the scheduling of patients offered a wide range of choice, and that the atmosphere was calm and
professional. The dedicated decontamination area impressed the assessor with its efficiency and
high standards.
16
Achievement against Quality
Improvement Priorities for 2012/13
Most Engaged Staff
Implementation of a nurse leadership and development programme
We are passionate about investing in our staff. We believe that exceptional people are created
through investment in capability and confidence. The provision of exceptional clinical care for our
patients is dependent on enhancing our staff. Therefore, we developed a bespoke programme
tailored to the individual leadership requirement of our Lead Nurses. To facilitate their learning to
become transformational leaders they undertook a 360 degree leadership profile.
The course explored the following themes:
x
Setting the Destination ± engaging people behind your vision, linking to the quality and value
agenda. Using the tools of involvement and enthusiasm. Identifying key supporters and how to
work with them to drive the vision
x
Personal Leadership ± personal organisation, setting your own goals, use of time, personal
effectiveness, when to say no, focusing on impact rather than action, balancing performance
with performance capability
x
Interpersonal Leadership ± fostering and developing trust, the tools which generate trust and
how WRXVHWKHP0DNLQJWKHPRVWRIWKHLUFOLQLFDOUHODWLRQVKLSV7KHGR¶VDQGGRQ¶WV7KH
importance of personal values and the little things which make a huge difference in generating
loyalty. Setting clear boundaries and generating respect and personal credibility
x
Influencing others and personal ability ± use of verbal and non-verbal communication, questions
and re-framing techniques to bring people to beneficial outcomes. Understanding others and
empathy, listening and connecting with others, the art of persuasion within existing and future
political climates
x
Team Leadership ± fostering teamwork and innovation inside and outside their Clinical Units,
facilitating cross-IXQFWLRQDOWHDPZRUNDQGDOOLDQFHVFKDOOHQJLQJWKHµROGUXOHV¶UHLQIRUFLQJWKH
no-go areas. Generating a proactive mentality within the team
x
Seeds for the Future ± dealing with change. Creating a safe place for change to work. The
pace of change, dealing with people who are resistant to change, creating support mechanisms
and enabling skill transfer. Taking teams from good to great.
We are extremely proud that this course was accredited by Coventry University. This course has
evaluated well and a further 360 degree profile at the end of the programme demonstrated
improvements in leadership behaviours. As an output of the Leadership Programme, the Lead
Nurses have developed, tested and implemented a Preceptorship programme across the
Treatment Centre. Preceptorship RIIHUVDEXGG\PHQWRUFDOOHGDµSUHFHSWRU¶WRVXSSRUWWKHQHZO\
registered/ new nurse to an area. This helps to guide our new nurses through an induction period
and support them to achieve the desired competencies for their respective clinical area.
17
Review of Quality Performance 2012/13
Best Clinical Outcomes
Incident Reporting
At the Nottingham NHS Treatment Centre, we believe that incident reporting provides a unique
and valuable opportunity to learn from our mistakes and allows us to implement prompt and
effective safety solutions. We recognise that in order to have both a positive and informative
reporting system, we need to maintain a culture where staff feel able to report incidents without
fear of reprisal or blame.
An organisation with high incident UHSRUWLQJLVDPDUNRIDµKLJKUHOLDELOLW\¶RUJDQLVDWLRQResearch
shows that organisations with significantly higher levels of incident reporting are more likely to
demonstrate other features of a stronger safety culture, such as a high patient satisfaction rate,
positive peer review assessments and a low number of clinical negligence claims. Our
commitment to reporting demonstrates a commitment to our patients and their safety. This is
recognised by the Care Quality Commission Essential Standards of Quality & Safety and further
reinforced by the Report of the Mid Staffordshire NHS Foundation Trust chaired by Robert Francis
QC (February 2013). An organisation with a high reporting rate of no harm incidents is a safe
place to be.
Our staff reported a total of 2,109 incidents in 2012/13 as opposed to 1,897 incidents in 2011/12;
this represents an increased reporting rate of 11%. Incident reporting represented 1.1% of our
annual activity for 2012/13 as opposed to 0.9% of our annual activity in 2011/12.
240
220
200
180
2012/13
160
2011/12
140
120
100
80
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
Jan
Represents an anticipated dip whereby a new incident e-reporting system was being implemented
18
Feb
Mar
Review of Quality Perf
rformance 2012/13
The top 5 incident categories for 2012/13 are detailed below and we have used this information to
inform our Quality Improvement Priorities for 2013/14:
Consent,
Confidentiality or
C
i ti
Infras
Res
1
Clinical
assessment
11%
Serious Incidents and Never Events
Serious Incidents are defined as µincidents where care management failures are suspected, which
result in serious neglect, serious injury, major permanent harm or death (or the risk of) to a patient
as a reVXOWRI1+6IXQGHGKHDOWKFDUH¶
Never Events are defined as µserious, largely preventable patient safety incidents that should not
occur if the available preventative measures have been implemented ¶.
Two Serious Incidents were identified during 2012/13; one of which was also classified as a Never
Event.
Description of the
Incident
Extraction off tooth
from the wrong side
of the mouth
Incident
Classification
Serious
Incident/Never Event
Learning
x
x
x
Fractured Neck of
Femur
Serious Incident
x
A review of the paperwork utilised has confirmed that the WHO
(World Health Organisation) checklist fully compli es with the
requirements of the NPSA Patient Safety Alert WHO Surgical
Safety Checklist (Ref. NPSA
A//2009/PSA002/U1)
Monthly spot check WHO checklist audits are undertaken
focusing on the sign in, time out and sign out
A review of all incident data has confirmed that there have been
no previous incidents identified associated with the WHO
checklist
A Falls screening tool will be developed, piloted and implemented
for relevant patients based on risk factors
19
Review of Quality Performance 2012/13
Stop the Line & Learning the Lessons
Since the introduction of our Stop the Line Campaign in October 2012, our staff have felt
empowered to µStop the Line¶ on 11 occasions.
Description of the
Incident/Event
Inconsistent practice in the
checking of accountable items
within operating theatres which
did not meet national best
practice guidelines
Clinical Unit
Day Case
Learning/Actions
x
x
x
An audit of Controlled Drugs
was undertaken by the
Pharmacy Lead and the
Accountable Officer; a number
of record keeping issues were
identified in 3 of the 5 Day Case
theatres
Day Case
x
x
x
x
x
A patient who was referred for a
surgical termination of
pregnancy was cancelled as a
concern was raised with regard
to gestation and a potential
breach in association with
established guidelines and
legislation
Day Case
x
x
x
x
x
x
x
A picking and distribution error
led to five patients receiving
Ondasetron (anti-emetic)
instead of Senna (bowel
preparation) as part of their
bowel preparation prior to an
Endoscopy procedure
Endoscopy
An email containing patient
identifiable information was
sent to a generic email box and
it was later discovered that
several parties had access to
this information
Cancer Team
x
x
x
x
x
x
x
The Standard Operating Procedure (SOP) for accountable
items was reviewed to ensure it met with AfPP
(Association for Perioperative Practice) guidelines
A review of the Care Pathway documentation was
undertaken; the swab count documentation was removed
to ensure that only white boards were used in line with
AfPP Guidelines
On the spot audits are undertaken to check compliance
with Association for Perioperative Practice (AfPP)
guidelines
The Standard Operating Procedure (SOP) for Controlled
Drugs was reviewed to ensure it met with legislation; the
SOP has been reviewed and ratified by the Medicines
Management Committee (MMC) and the Clinical
Governance & Risk Management Committee (CGRM)
Additional Controlled Drugs training has been provided to
all Day Case staff
An updated signature register has been compiled
The quarterly audit has been increased to monthly and is
undertaken by the Day Case Clinical Unit in conjunction
with the Accountable Officer and Pharmacy Lead
New sharps bins with absorbent mats are in use within
each theatre and recovery area for safe disposal of
unused Controlled Drugs
New Controlled Drugs registers are now in use
The patient was referred to an alternative appropriate
centre
Confirmation was provided to the Clinical Unit that they
were registered to treat up to a gestation of 14 weeks.
All consultants were contacted to confirm gestation that
they were comfortable to treat in relation to their own
clinical practice
The Day Case Administration Manager reviews all patients
with a higher gestation to ensure they are booked
appropriately
Daily telephone calls are held with referring parties to
ensure appropriate escalation and booking
Quarterly Meetings are now held with the two main
referring parties to address any issues with the pathway
Written communication was sent to all patients following
telephone discussion
All patients awaiting investigation were asked not to take
the incorrect drug; the medical records of the patients who
had already undergone the procedure were reviewed and
no harm was identified
A new check and receive process for medication was
implemented
Information Governance Training has been delivered to
administrative staff at the Treatment Centre
Generic email boxes have been reviewed for
appropriateness of use
A safe list of generic email boxes has been compiled
Owners of email boxes were asked to review staff access
and check appropriateness
20
Review of Quality Performance 2012/13
Description of the
Incident/Event
Whilst undergoing Day Case
surgery, a patient experienced
an unexpected intra-operative
bleed and unintentional fluid
overload. The patient required
an emergency blood
transfusion. There were
procedural issues associated
with obtaining the blood and a
delay in subsequent transfer to
the Acute Hospital Trust
Four of the planned seven
patients on the STOP (Surgical
Termination of Pregnancy)
theatre list did not have any of
the necessary accompanying
documentation from the
referring service. Upon arrival,
all four patients were given
misoprostol prior to the
documentation being located
and their admission being
completed
There was a delayed start to an
operating list as stock
medication items were not
available in the Day Case Unit
to commence induction of
patient anaesthetic
Clinical Unit
Day Case
Learning
x
x
x
Day Case
x
x
x
x
x
Day Case/
Pharmacy
x
x
x
x
Extraction of tooth from the
wrong side of the mouth
(Serious Incident/Never Event)
Day Case
x
x
x
A power outage was caused by
a power dip due to a fault on the
grid network that the Treatment
Centre is connected to and a
reboot was undertaken; the first
of 3 UPS systems (battery
back-up) was broken and the
second was damaged. Due to
the increasing risk of power
disruption due to tram works,
patients were cancelled and
there were problems obtaining
parts.
Patients were being allocated to
the incorrect clinic resulting in
cancellations and
inconvenience as a result of
substandard practices around
the vetting of referrals
Day Case
x
x
x
Digestive
Diseases
x
x
x
The Collection of Emergency Blood SOP (Standard
Operating Procedure) was updated and escalated to all
facilitators
Staff training was reviewed to include scenario training,
blood collection theory and scenario, use of Glycine intraoperatively, setting up emergency transfer trolley and
arterial lines
A process was established whereby the Blood Gas
machine is checked by the ALS (Advanced Life Support)
Lead and instruction left that when out of commission the
ALS provider is to be informed
Documentation from referring parties to be sent via
recorded post and delivered to Day Case immediately
The Standard Operating Procedure (SOP) for
Administration of Misoprostol was revised and circulated
Patient admissions are to be completed by nursing staff
Clinicians are to consent the patient and discuss risks of
misoprostol
Nurses are to provide the patient with Misoprostol for the
patient to self-administer following a discussion of the risks
with the clinician
Additional Controlled Drugs training has been provided to
all Day Case staff
An updated signature register has been compiled
Storage capabilities on the unit have been reviewed and
revised arrangements made for the storage of additional
stock items
Supply issues were addressed directly with suppliers
A review of the paperwork utilised has confirmed that the
WHO (World Health Organisation) checklist fully complies
with the requirements of the NPSA Patient Safety Alert
WHO Surgical Safety Checklist (Ref.
NPSA/2009/PSA002/U1)
Monthly spot check WHO checklist audits are undertaken
focusing on the sign in, time out and sign out
A review of all incident data has confirmed that there have
been no previous incidents identified associated with the
WHO checklist
The switch gear timer which actives the generator was recalibrated
All UPS Systems have now been replaced to ensure there
are adequate back-up systems in place
The escalation process has been simplified
A vetting criteria was developed for nursing staff to follow
There were dedicated vetting sessions established at
designated times daily to facilitate allocation to the correct
clinics
Key contact times with the lead nurse have been built into
the working day
21
Review of Quality Performance 2012/13
Safety Alerts
Alerts issued via the Central Alerting System (CAS) relate to key safety issues that have the
potential to cause harm if not acted upon promptly. Safety alerts are an important source of
information which enables us to ensure that the safety of our clinical services is our first priority.
Timely and effective implementation of safety alerts form part of the CQC (Care Quality
Commission) Essential Standards of Quality and Safety. Failure to implement safety alerts could
result in incidents, complaints, claims and/or inquests and have a significant impact on both staff
morale and patient confidence.
The Nottingham NHS Treatment Centre received 133 safety alerts during 2012/13, 18 of which
were applicable to all/some of the services that we provide; 7 Medical Device Alerts, 5 Drug Alerts
and 6 CMO (Chief Medical Officer) alerts. All CAS alerts were sent to the Clinical Units within 24
hours of receipt; they were actioned and closed within the relevant timescales.
Best Patient Experience
Claims
There have been no successful claims against the Nottingham NHS Treatment Centre during
2012/13.
Patient Surveys
At the Nottingham NHS Treatment Centre, we believe that patient feedback is essential as it
provides a rich source of information about the quality of the services we provide. As an
organisation we have set out the key principles in our Credo to ensure we listen and act upon what
our patients tell us. We have developed a number of ways to do this but feel that by far the most
effective way has been through the development of a rapid response card providing real time
information which is promptly acted upon by the clinical teams.
(YHU\SDWLHQWLVRIIHUHGWKHRSSRUWXQLW\WRSURYLGHµUHDO WLPH¶IHHGEDFNIROORZLQJHDFKDWtendance
via the postcard which asks 3 simple questions:
x
What did we do well? (free text)
x
What could we have done better? (free text)
x
Would you recommend us to family/friends? (yes or no)
22
Review of Quality Performance 2012/13
During 2012/2013, 16% (29,349) of our patients completed a feedback card. Of those 28,957
patients who responded to the question µwould you recommend us to you family and friends¶ a
staggering 99.3%of
stated
that they would.
Review
Quality
Performance 2012/13
When we asked our patients what did we do well:
x
18,197 patients said they had had a really positive overall experience
x
2,775 patients said that they had received excellent customer care
x
1,279 patients said they had had a positive experience with regard to waiting times
When we asked our patients what we could have done better:
x
1,579 patients said they had had a negative experience with regard to waiting times
x
310 patients said that they had experienced problems associated with communication
x
244 patients said they felt that the environment was uncomfortable
During 2012/13, we also introduced the Net Promoter Score (NPS), more commonly known as the
µIDPLO\DQGIULHQGVWHVW¶7KHVWDQGDUGTXHVWLRQWKDWZHXVHLVµKRZOLNHO\LVLWWKDW\RXZRXOG
UHFRPPHQGXV"¶DQGUHVSRQGHQWVindicate this likelihood on a 5-point rating scale. Those
indicating µextremely likely¶ are promoters, those indicting µunsure, unlikely or not at all¶ are
detractors and those µlikely¶ are passively satisfied or neutral. The NPS is the difference between
the percentage of users who are extremely likely to recommend our services (promoters) minus
the percentage of those who would not (detractors). A score of 75% or above is considered quite
high. Following the introduction of the NPS in July 2012, we have had a total of 17,165 promoters,
3,550 passives and 291 detractors; our NPS for 2012/13 was 80%.
This year, we were enthusiastic about demonstrating that the feedback we received from each of
our clinical services was pro-actively used locally to make improvements in those areas which
really matter to our patients. As such, we are extremely proud to feature details within Part 3 of
this Quality Account about what our Clinical Units have done with the feedback that they have
received from their patients.
23
You really OLNHG«
24
You would like to see better...
25
Review of Quality Perf
rformance 2012/13
Complaints, Concerns, Comments, Compliments & PALS
At the Nottingham NHS Treatment Centre, we place feedback from our patients at the very
heart of our service and utilise this feedback to ensure that we are maintaining high
standards of care. We operate a complaints process that responds flexibly, prompt ly and
effectively to the justifiable concerns of complainants, which therefore enables us to
address unacceptable practices promptly, support complainants effectively and promote
public confidence in our services.
314 pieces of feedback were received during 2012/13; comprised of 94 complaints, 23
concerns, 74 comments, 73 PALS (Patient Advice & Liaison Service) enquiries and 50
compliments.
Concern
7%
Com
nts
Complaints and concerns represent 37% of the feedback we received during 2012/13.
However, in comparison to the previous year, there has been a reduction of 15% in the
number of complaints and concerns received. This is not incidental and is reflective of the
excellent work that we have been doing to resolve patient, family and carer complaints and
concerns as early as possible. This ensures our patients receive a prompt response to the
matters they have highlighted and we respond to all PALS within 24 hours. We also strive
to provide support for those patients who feel they do not want to make a formal complaint
at that stage of their care.
26
Review of Quality Perf
rformance 2012/13
140
120
100
Concerns
80
Complaints
60
40
20
0
2010/11
2011/12
2012/13
The top 5 themes from complaints and concerns during 2012/13 are as follows and we have
used this information to feed into our Quality Improvement Priorities for 2013/14:
Attitude and
Behaviour
11%
nical
atment
9%
Communication
21%
Appointments/
Delay/
Cancellation/
Waiting Times
26%
Standard of
Medical Care
13%
27
Quality Improvement Priorities for 2013/14
Q u ali ty
Domain
Patient
Experience
Our Quality Priorities for 2013/14
Success Measures for 2013/14
µ6LPSO\WKHEHVWSDWLHQWH[SHULHQFH¶
We promise to listen to what our patients
want and use the feedback to continually
enhance the patient experience
x
x
A minimum return rate of 20% will be achieved in
relation to patient feedback cards
The Treatment Centre will achieve an average Net
Promoter Score for the financial year that will feature in
the top quartile for the region
µ1RGHFLVLRQDERXW\RXZLWKRXW\RX¶
We will continue to empower our patients;
decision about your care will be based on
a combination of your experience of your
condition DQG\RXUFOLQLFLDQ¶VH[SHUWLVH
µ5LJKWILUVWWLPH¶
Righ
ht appointment, right clinician, most
convenient location
x
The Right Care Decision Aid will be piloted
x
x
Text reminders for appointments will be piloted
Increased access to clinics in the community will be
implemented
Unnecessary attendances will be reduced
x
Patient
Experience,
Patient Safety
& Clinical
Effectiveness
µ([FHOOHQFHGHOLYHUHG¶
We will make sure that our people have
the right knowledge and skills to deliver
the best possible care
x
x
The NHS Stafff survey will be undertaken
A supervision framework will be developed and
implemented. Compliance against policy will be
reviewed
µCaring for you and caring about you ±
x
See the person in the patient¶
We promise to make sure that you get the
right clinical care provided by
compassionate and caring staff
x
The Patient First Compassion in Care Framework will
be audited monthly
A falls screening tool will be developed, piloted and
implemented for patients over 75 years
90% of direct hire staff will undertake a dementia
awareness programme
90% of direct hire clinical staff (including healthcare
assistants) will be trained in the principles off the Mental
Capacity Act 2005
A patient information pod will be introduced and
evaluated
The relevant recommendations from the Francis Report
2013 will be implemented
x
x
x
x
Patient Safety
µ6DIHW\ILUVWHYHU\WLPH¶
Your safety will be our first priority
x
x
x
x
Clinical
Effectiveness
µ%HWWHUWKDQWKHUHVW¶
We will continually improve the quality of
our services by demonstrating that we
both meet and exceed national peer
review standards
x
x
x
28
:HDLPWRKDYH=(52³QHYHUHYHQWV´
There will be repeat audits around the WHO surgical
safety checklist in Day Case to demonstrate improved
compliance
A WHO audit will be undertaken within Skin Surgery
Applicable NICE guidance will be implemented and
audited
Compliance with JAG accreditation will be maintained
ISO accreditation will be maintained
Skin cancer peer review accreditation will be
maintained
:K\WKLVLVLPSRUWDQWWRXV«
x
x
x
x
x
x
x
x
x
We want to actively listen to what you and your carers want from your healthcare service and will
assist you in having a voice
We want you to know that we care about your experience and that we are committed to making
improvements and will share them with you and the public
We want to ensure we capture the views of µthHVPDOOJX\¶DVZHOODVWKHELJ
We want to continually assure ourselves that the services we offer deliver excellence every time
We want to demonstrate that we are your provider of choice
We believe you should be an equal partner in making decisions about your care
We will provide you with the knowledge and expertise to assist you in making a shared decision
We will help you work through your choices and voice your expectations
We will honour you choice and support you in your on-going care
Monitoring &
Reporting
Responsibilities
Executive Board
Executive Board
x
x
We want to ensure that you only attend for an appointment when you absolutely need to
We are committed to making sure that you see the right clinician at the right appointment in the
best location for you
Executive Board
x
We want to understand how our staff feel and what challenges they face in their day to day roles
to enable us to make improvements which support excellent practice and iPSURYHRXUSDWLHQWV¶
experience
Supervision is an important aspect of ensuring staff have an opportunity to reflect on practice,
share their views and receive feedback that promotes safe, quality care in line with our statutory
obligations to meet Care Quality Commission compliance and support the recommendations of
the Francis Report 2013
We want to ensure that our staff skills and competence meet the needs of the patient
demographic we serve. As such, our Patient First Strategy for this year will focus on dementia
and falls which form part of the National CQUIN (Commissioning for Quality & Innovation) and
reward excellence. The introduction of a falls screening tool will build upon the existing
processes in place and help our staff to support those patients at a high risk of falling. Our
dementia awareness programme will help our staff to deliver improved care to those patients who
are the most vulnerable
We want to support you so that you can be actively involved in your clinical care regardless of
your capacity. In order to do this, our staff need to understand what they can put in place to
support you to make decisions about your care
We are committed to ensuring that you have access to relevant and targeted public health
information via the introduction of a patient information pod
We are committed to implementing the recommendations of the Francis Report 2013
Executive Board
We will ensure every surgical procedure is undertaken by a team committed to putting your safety
first and promote a culture of zero tolerance to non-engagement
:HZLOOHQVXUHWKDWRXUVWDIIµVKRXWRXW¶ZKHQWKH\SHUFHLYH\RXUVDIHW\LVFRPSURPLVHGDQG
ensure solutions are put in place promptly
Executive Board
We want to support safe and effective patient care, stimulate continuous improvement in
processes and patient outcomes, and maintain your confidence in our Endoscopy services by
maintaining JAG accreditation
We want to be assured that we are handling your information in a safe and secure way that
maintains the confidentiality of your patient record by maintaining ISO accreditation
We want to deliver improved care for people with cancer and their families by ensuring services
are as safe as possible, improving the quality and effectiveness of care and encouraging the
dissemination of good practice by maintaining peer review accreditation
Executive Board
x
x
x
x
x
x
x
x
x
x
29
Executive Board
Mandatory Statements
Review of Services
During 2012/13 the Nottingham NHS Treatment Centre provided and/or sub-contracted 12 NHS
Services. The Nottingham NHS Treatment Centre has reviewed all the data available to them on
the quality of care provided in 12 of these NHS 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 NHS services by the Nottingham NHS Treatment
Centre for 2012/13.
Participation in Clinical Audits & National Confidential
Enquiries
During 2012/13, 12 national clinical audits and no national confidential enquiries covered NHS
Services that the Nottingham NHS Treatment Centre provides.
During that period the Nottingham NHS Treatment Centre participated in 100% of national clinical
audits and 100% 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 Nottingham NHS Treatment
Centre was eligible to participate in, actually 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 registered cases required by the terms of that audit or enquiry.
NCAPOP
audit?
Participated
Yes/No?
If yes,% of
cases
submitted
Adult asthma (British Thoracic Society)
No
Yes
100%
Bowel cancer (NBOCAP)
Yes
Yes
100%
Bronchiectasis (British Thoracic Society)
No
Yes
100%
Elective surgery (National PROMs Programme)
No
Yes
100%
Heart failure (HF)
Yes
Yes
100%
Heavy Menstrual Bleeding
Yes
Yes
100%
Inflammatory bowel disease (IBD)
Yes
Yes
100%
Lung cancer (NLCA)
Yes
Yes
100%
National Cardiac Arrest Audit (NCAA)
No
Yes
100%
National Vascular Registry
No
Yes
100%
Oesophago-gastric cancer (NAOGC)
Yes
Yes
100%
Pulmonary hypertension
No
Yes
100%
6
12
100%
Name of National Clinical Audit/
National Confidential Enquiry
Total
30
Mandatory Statements
The reports of 12 national clinical audits were reviewed by the provider in 2012/13 and the
Nottingham NHS Treatment Centre intends to take the following actions to improve the quality of
healthcare provided:
x Continue to proactively support all Clinical Units to ensure participation in national clinical audit
and national confidential enquiries where eligible.
x Encourage and promote learning from national clinical audit and national confidential enquiries
where they are applicable to the services we offer.
x Share the outcome of national clinical audit and national confidential enquiries at the Clinical
Governance & Risk Management Committee (CGRM) to encourage staff engagement, share
the learning and ensure continuous quality improvement of all our services.
The local clinical audits that the Nottingham NHS Treatment Centre participated in during 2012/13
are as follows:
Status
% of cases
submitted
Audit of Alitretinoin use against NICE Guidance
Ciclosporin monitoring audit
Erythemas in phototherapy patients, caused by patient noncompliance or non-treatment-related factors
x Malignant Melanoma Record keeping of clinical features
x 2 Week wait Referrals
x Fumaderm re-audit
x Prescription audit on adult patients
x Survey of Dermatology Knowledge in Nottinghamshire
x Review of Narrowband UVB in Dermatology
x Photodynamic Therapy (PDT) clearance rate
Cardiology, Vascular & Respiratory
Completed
Completed
100%
100%
Completed
100%
Completed
Completed
Completed
100%
100%
100%
Completed
Completed
100%
100%
Completed
Completed
100%
100%
x Home Ventilation Audit
x Patients understanding diagnostics and pathway
x Improvement in service to patients needing home ventilation
x Stockings after vein surgery
Radiology
In progress
In progress
Completed
Completed
100%
100%
100%
100%
Completed
100%
Completed
Completed
Completed
Completed
100%
100%
100%
100%
Completed
100%
Completed
100%
Name of Local Clinical Audit
Dermatology
x
x
x
x
Cannulation Audit ± November 2012 & April 2013
x Card vs E-requesting Audit
x Radiation Protection Audit
x Plain-film ± auto reporting Audit
x Rheumatology reporting Audit
Orthopaedics
x
x
Quickdash scoring - Carpal Tunnel
Invasive MOXFQ Report
31
Mandatory Statements
x Podiatric Surgery Invasive Procedures
x Invasive Fixations Report
x Invasive Medications Report
x Invasive Anaesthetic Report
x Invasive Pst Treatment Sequeliae
x Invasive PSQ10 Response
x Extra patients on hand dressing list
x Hand Dressing Audit
Endocrinology & Rheumatology
x Vaccination in patients with inflammatory rheumatic
conditions
x Patient satisfaction of hyperthyroid telephone clinic
x Steroid replacement audit
x Biologics in non-NICE indications
x Compliance with BTS/TB guidelines
x Nurse prescribing audit
x Audit of generic nurse lists
x Audit of recording DAS scores for RA monitoring
x Prospective audit of compliance for new start biologics
Gynaecology
x
x
x
x
HPV (human papillomavirus) Audit
Nurse-led smear
Dexa Audit
Thyroxin in early pregnancy for women with recurrent
miscarriage
Day Case
x
x
x
x
x
WHO checklist compliance
Wound Infection, Admission Rates, Pain & Post Operative
Nausea rates occurring in recovery, at 24 hours and at 28
days
Recovery following Wisdom Tooth extraction
Mystery Shopper Survey
Patient Satisfaction Feedback Cards
x
x
Admission Rates following day surgery & causes
Association for Peri-Operative Practice (AfPP) Regulatory
Audits (health & safety, documentation checks, professional
standards, infection control)
x 3DWLHQW&DQFHOODWLRQDQG³'LG1RWAttend '1$´DXGLWV
x Pre-Operative Assessments on day of surgical clinic
Endoscopy
x
x
Number of Procedures Performed by Each Operator
Success of Intubation of OGD
32
Completed
Completed
Completed
Completed
Completed
Completed
Completed
Completed
100%
100%
100%
100%
100%
100%
100%
100%
In progress
100%
In progress
100%
In progress
In progress
Completed
Completed
Completed
Completed
Completed
100%
100%
100%
100%
100%
100%
100%
Completed
Completed
Completed
100%
100%
100%
Completed
100%
In progress
100%
In progress
100%
Completed
In progress
In progress
In progress
100%
100%
100%
100%
In progress
100%
In progress
In progress
100%
100%
Completed
Completed
100%
100%
Mandatory Statements
(oesophagogastroduodenoscopy)
Completed
Completed
100%
100%
Completed
Completed
Completed
Completed
100%
100%
100%
100%
x Colonic Polyp Recovery
x Correct Identification of Position of Colonic Tumours
x Patient Survey
x Patient Comfort and Anxiety Scores
Digestive Diseases
Completed
Completed
Completed
Completed
100%
100%
100%
100%
x Clinic Waiting Times
Total
Completed
64
100%
100%
x
x
x
x
x
x
Completion of OGD (oesophagogastroduodenoscopy)
Colonoscopy Completion Rate
Adenoma Detection Rate
Sedation and Analgesia for Colonoscopy
Quality of Bowel Preparation
Repeat Endoscopy for Gastric Ulcers within 12 weeks
The reports of 64 local clinical audits were reviewed by the provider in 2012/13 and the
Nottingham NHS Treatment Centre intends to take the following action to improve the quality of
healthcare provided:
x
x
x
x
Continue to proactively support all Clinical Units in the development of annual clinical audit
plans
Encourage participation and promote learning from all local clinical audits
Utilise the outcome of local clinical audits to build upon the quality of service provision and
improve the patient experience
Share the outcome of local clinical audits at the Clinical Governance & Risk Management
Committee (CGRM) to encourage staff engagement, share the learning and ensure continuous
quality improvement of all our services
Many of our patients have a shared care pathway moving between the Treatment Centre and
Nottingham University Hospitals NHS Trust. Where the Treatment Centre only manages a small
parWRIDSDWLHQW¶VSDWKZD\DQDJUHHPHQWLVLQSODFHWKDWLQIRUPDWLRQZLOOEHXWLOLVHGIURPWKH
shared healthcare record and included in the relevant shared audits.
In addition to participating in national clinical audits, national confidential enquiries and local
clinical audits, the Nottingham NHS Treatment Centre also undertake a facility wide programme of
audits in relation to the following areas: Health & Safety, Information Governance, Medical
Records, Infection Prevention & Control, Hand Hygiene, Fire Safety, Medical Gases, Controlled
Drugs and Decontamination.
Participation in Clinical Research
The Nottingham NHS Treatment Centre jointly hosts clinical research in conjunction with
Nottingham University Hospitals NHS Trust. The number of projects related to NHS services
33
Mandatory Statements
provided by the Nottingham NHS Treatment Centre in 2012/13, that were undertaken during that
period, and that relate to research approved by a Research Ethics Committee, were 29.
All research proposals undergo rigorous checks before clinical research can be undertaken at the
Nottingham NHS Treatment Centre. Applications are made via the Local Research Ethics
Committee before approval is considered. The increasing level of agreement to support clinical
research demonstrates our commitment to improving the quality of care we offer and contributing
to wider health improvement.
Registration and External Review
The Nottingham NHS Treatment Centre is required to register with the Care Quality Commission
and its current registration status is Compliant. The Care Quality Commission has not taken
enforcement action against Nottingham NHS Treatment Centre during 2012/13. The Nottingham
NHS Treatment Centre has the following conditions on registration:
Site
The Nottingham NHS Treatment Centre,
Lister Road,
Nottingham
NG7 2FT
Regulated Activity
x
x
x
x
x
Lister House Surgery, 207 St Thomas Road,
Peartree, Derby, Derbyshire, DE23 8RJ
Nottingham Road Clinic, 195 Nottingham Road.
Mansfield, Nottinghamshire, NG18 4AA
Parkview Medical Centre, Cranfleet Way, Long
Eaton, Nottinghamshire, NG10 3RJ
Southwell Medical Centre, The Rope Walk,
Southwell, Nottinghamshire, NG25 0AL
Stoneleigh House, 209 Victoria Avenue, Borrowash,
Derby, Derbyshire, DE72 3HT
The Meadowfields Practice, Fellow Lands Way,
Chellaston, Derby, Derbyshire, DE73 6SW
Torkard Hill Medical Centre, Farleys Lane, Hucknall
Nottingham, Nottinghamshire, NG15 6DY
x
x
Conditions
Treatment of disease, disorder
or injury
Diagnostic and screening
procedures
Surgical procedures
Family Planning
Termination of pregnancies (of
pregnancy for patients at no
more than fourteen weeks (14)
gestation within the Nottingham
NHS Treatment Centre)
Regulated
activity must
not be
undertaken
on persons
under the
age of 14
years
Diagnostic and screening
procedures
Treatment of disease, disorder
or injury
None
The Nottingham NHS Treatment Centre has not participated in any special reviews or
investigations by the CQC during the reporting period. However the Nottingham NHS Treatment
Centre was subject to an unannounced visit by the Care Quality Commission during 2012/13. The
following standards were subject to review:
34
Mandatory Statements
x
x
x
x
x
Consent to care and treatment (Outcome 2): Before people are given any examination, care,
treatment or support, they should be asked if they agree to it
Care and welfare of people who use services (Outcome 4): People should get safe and
appropriate care that meets their needs and supports their rights
Safeguarding people who use services from abuse (Outcome 7): People should be protected
from abuse and staff should respect their human rights
Supporting workers (Outcome 14): Staff should be properly trained and supervised, and have
the chance to develop and improve their skills
Assessing and monitoring the quality of service provision (Outcome 16): The service should
have quality checking systems to manage risks and assure the health, welfare and safety of
people who receive care
No areas of concern were identified and the final report can be reviewed at:
http://www.cqc.org.uk/directory/1-120587279
Commissioning for Quality and Innovation (CQUIN)
Payment Framework
The Nottingham NHS Treatment Centre income in 2012/13 was not conditional on achieving
quality improvement and innovation goals through the Commissioning for Quality and Innovation
payment framework because the facility is an Independent Sector Treatment Centre and therefore
not on the NHS Standard Contract for Acute Services.
Data Quality
The Nottingham NHS Treatment Centre maintains a high level of data quality and on an ongoing
basis will be taking the following action to continuously improve data quality:
x
Quarterly (at minimum) performance meetings to review performance data, identify any areas
of improvement and monitor implementation of those improvements.
Secondary Uses Service
The Nottingham NHS Treatment Centre 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.
7KHSHUFHQWDJHRIUHFRUGVLQWKHSXEOLVKHGGDWDZKLFKLQFOXGHGWKHSDWLHQW¶VYDOLG1+61XPEHU
was:
x 100% for admitted patient care
x 100% for outpatient care
7KHSHUFHQWDJHRIUHFRUGVLQWKHSXEOLVKHGGDWDZKLFKLQFOXGHGWKHSDWLHQW¶VYDOLGGeneral Medical
Practice Code was:
x 100% for admitted patient care
x 100% for outpatient care
35
Mandatory Statements
Information Governance Toolkit
The Nottingham NHS Treatment Centre Information Governance Assessment Report score overall
score for April 2012 ± March 2013 was 82% and was graded Green.
Payment by Results
The Nottingham NHS Treatment Centre was not subject to the Payment by Results clinical coding
audit during 2012/13 by the Audit Commission.
Revalidation
The Nottingham NHS Treatment Centre has participated in the Organisational Readiness selfassessment for year ending 31 March 2013. Compliance is monitored quarterly by the Circle
Partnership Integrated Governance Committee.
Safeguarding
The Executive Board is accountable for and committed to ensuring the safeguarding of children in
their care. The Treatment Centre also has a responsibility to liaise with other agencies and provide
information to them where necessary, to ensure the ongoing safety of children once they leave our
care. In 2012-13 there were 967 individual contacts by children including outpatient and day case
DSSRLQWPHQWV 7KH 7UHDWPHQW &HQWUH¶V VDIHJXDUGLQJ FKLOGUHQ¶V WHDP DUH FRPSULVHG RI DQ
Executive Lead, a Named Nurse and a Named Doctor who attend the Operational Management
Board, a sub-committHH RI WKH /RFDO 6DIHJXDUGLQJ &KLOGUHQ¶V %RDUG DQG WKH 6DIHJXDUGLQJ
Partnership meetings.
Circle has a safeguarding policy that applies to all its facilities including the Treatment Centre
which was reviewed and ratified In July 2012. The Treatment Centre adheres to the
Nottinghamshire Local Authority safeguarding procedures. All policies are available to staff via the
electronic policy library.
In accordance with the Intercollegiate Document published in September 2010 the Treatment
Centre provides all staff with Level 2 training in safeguarding and provides an update every 3
years. An annual staff leaflet is circulated which provides the contact details of the safeguarding
leads and other useful numbers. 91% and 100% of our staff were trained at level 2 and Level 3
respectively in 2012.
7KH 7UHDWPHQW &HQWUH KDV XQGHUWDNHQ WKH (DVW 0LGODQGV 6WUDWHJLF +HDOWK $XWKRULW\¶V DVVXUDQFH
IUDPHZRUN µ7KH 0DUNHUV RI %HVW 3UDFWLFH¶ ,Q DGGLWLRQ VDIHJXDUGLQJ LVVXHV DUH UHSRUWHG WR WKH
Clinical Governance and Risk Management Committee (sub-committee of the Executive Board)
which meets monthly. The Executive Board takes the issue of safeguarding extremely seriously,
and receives an annual report on safeguarding children.
36
Dermatology Quality Account 2012/13
About the Clinical Unit
Dermatology Services are situated in Gateways A and G of the Nottingham NHS Treatment Centre
and offer a diverse range of clinical expertise in both an outpatient and Day Case setting. We
place our Credo at the heart our service and provide a cohesive team approach which is focussed
on ensuring that all patients with skin diseases are treated in an environment where they are not
subjected to the stigma they experience outside the healthcare setting. We aim to develop and
build upon existing support mechanisms from our staff and other patients with similar skin
conditions and experiences thus providing increased patient confidence in what is often an
emotional time.
Services Provided
Tertiary Level services for Psoriasis, Vulva disease and Eczema, General Dermatology Outpatient
(including biologics), Skin Cancer Target clinics, Light Therapy, Day Case Treatments including a
wide range of topical treatments, Hand and Foot PUVA, Iontophorersis, Skin Surgery and Mohs
Micrographic Surgery, Wound Checks, nurse led Biopsy Service, Leg Ulcer clinic, Photo Dynamic
Therapy (PDT), Contact Dermatitis and Patch Testing clinic, Nurse led Systemic Therapy
monitoring, Nurse led Triamcinilone clinic and Botox treatment for Hyperhidrosis.
Achievement against Quality Improvement Objectives 2012/13
Quality
Domain
Patient Safety
Our Quality Priority for
2012/13
Ensure all patients are
booked onto the correct
clinic lists
Ensure healthcare
records are available for
all patients
Outcome
Status
All patients that have skin surgery now leave with a follow up
appointment. Clinic codes are now placed in all clinic rooms
and displayed in each theatre so that the correct clinic is
selected by the clinician and booked by the administration
staff appropriately.
Achieved
Each specialty has an early warning score card called the
Quality Quartet where access to records is monitored by the
Executive Board and breaches of tolerance are actioned.
Partially
Achieved
Medical record access has improved, however not all are
received in a timely manner. On these occasions an incident
form is completed and actioned accordingly.
Ensure pathology
results from NUH are
sent back to the correct
doctor by making sure
that the correct codes
are on all request forms
Pre-printed barcode labels are now in use which has reduced
the number of occasions where results have been sent to the
wrong clinician
Achieved
Ensure that patients are
safely monitored when
prescribed systemic
therapy. Adherence to
British Association of
Dermatologist (BAD)
guidelines.
The required monitoring criteria are recorded in medical
notes and clinical management plans have been revised to
reflect current best practice.
Achieved
Ensure the safe
administration of light
therapy is administered
to all patients
Closer working relationship with medical physics who
maintain the machines on a regular basis.
Achieved
All codes are displayed in all clinic rooms and theatres.
Interruptions of the therapy dose calculation has been
reduced. Area designated quiet zone, do not disturb notices
displayed
39
Dermatology Quality Account 2012/13
Patient
Experience
To return 10% of
feedback cards and
achieve 99%
satisfaction rates
The response rate Outpatients and Skin Surgery for this time
period was 6.5%. Ongoing work has been undertaken to
increase feedback card response rate (COS project). We
have seen variations in response from 3 to 7% for outpatients
and 5 to 53% for Skin Surgery.
Partially
Achieved
Recommendation rate was 99.3% and 80% Net promoter
Score
Clinical
Effectiveness
Reducing waiting times
by improving the
efficiency clinics
Clinic appointment slots have been adjusted to ensure
patientV¶ have the appropriate amount of time with their
clinician. This will continue to be a focus for next year
Achieved
Audit of biologic
prescribing
Annual audit to show compliance with current NICE
guidelines, which we continue to adhere to
Achieved
Learning from Clinical Audits
The learning that has been implemented as a result of national/local clinical audits is as follows:
x Ciclosporin (a drug affecting the immune response that is used for eczema or psoriasis)
monitoring audit - This audit monitored completion of forms of 30 patients regarding the dosage
of Ciclosporin. Patients¶ bloods were tested fortnightly and their blood pressure taken, the audit
monitored the completion of information from clinicians. Results from the audit have shown
that not all clinicians complete the necessary parts of the form; mainly creatinine was the
section which was often not completed. Clinical lead has discussed further with clinical team
and a re-audit will be undertaken to mark improvement.
x Fumaderm (a drug used for the treatment of adults with moderate to severe psoriasis) re-audit The audit monitored pharmacy records from June 2011 of those patients receiving Fumaderm
for relapsing psoriasis. The results showed that a significant proportion of patients will develop
gastrointestinal side-effects and blood and urine dip abnormalities will often settle when
effective treatment is undertaken but clearer documentation is needed. A re-audit will be
undertaken in 2013-2014.
x Prescription audit on adult patients - For this audit the information of 100 prescriptions were
monitored with patient consent. The audit indicated the incompletion of doctors¶ information on
prescriptions. Pharmacists were asked to contact the relevant clinician to obtain this
information on future prescriptions. Clinicians are advised to create model prescriptions on oral
medications including Methotrexate (a drug used for psoriasis). The model prescriptions will be
circulated to all clinicians and specialist nurses within the department.
x Photodynamic Therapy (PDT) clearance rate - This was a retrospective audit looking at the
recommended use of photodynamic therapy (a technique for treating skin cancers and sundamaged skin which might one day turn cancerous) for non-melanoma skin cancers including
basal cell carcinoma, actinic keratosis and intraepithelial carcinoma. From the results received
requests for histopathologists to report specimens as superficial or the depth of the tumour
should be specified on the request card.
Quality Review
Patient Comments
Gateway A has received over 3000 feedback cards from our patients. Patient Feedback has been
our key priority for 2013-13 so that the department can better understand what is important to our
patients and make improvements to meet patient needs. A multi-disciplinary view was taken on
how the number of cards could be increased. The key point identified was improving the retreival
of feedback cards from our patients. This has been achieved through better communication
between staff and patients and a focus on the importance of patient veiws. As can be seen the the
number of cards received has increased and this level has been sustained.
40
Dermatology Quality Account 2012/13
450
400
350
300
250
200
150
100
50
0
Apr
May
Jun
Jul
Aug
Sep
Dermatology Outpatients
Oct
Nov
Dec
Jan
Feb
Mar
Dermatology Surgery
Our patients told us:That over 65% of the cards stated that mutiple aspects of their visits were done well. Customer
Care and Efficiency were the next highest themes seen.
"Everything was explained perfectly. I was made to feel very comfortable and secure "
"Overall service is very good. Staff are friendly and attentive"
"Treated with respect at reception. On time. Made to feel comfortable"
We asked our patients what we could have done better. The themes identified are;You Said:
Efficiency - Waiting times
" Waited 1/2 hour after my
appointment time to see Doctor"
Environment - Comfort
³1RKLJKFKDLUVLQFOLQLF$ZDLWLQJDUHD
for disabled. Too low seating."
Communication - Information
³0RUH information regarding waiting
time for the biopsy procedure."
We Did:
Examples of work undertaken to address waiting times:
x Communicating with the patients and carers both in the atrium and in the
corridor, informing them of delays in clinic.
x Informing patients and carers as soon as they attend the desk of a
known delay.
x Using the television screens to keep patients and carers informed of any
delays.
Examples of work undertaken to address comfort:
x 2 high backed chairs now placed in reception in front of the reception
desk.
Examples of work undertaken to address information:
x Our patient information is reviewed on a regular basis, and amended
accordingly.
x Waiting times for biopsy can cover a number of aspects of the patient¶s
visit, for example how long the biopsy will take, and this will be explained
before the biopsy. The waiting time to be seen for a biopsy, we try to
biopsy patients on the day of their outpatient visit wherever possible. If
there is no availability on the day or the patient wishes to come back for
the procedure then they will always be booked, wherever possible within
1 week of the initial appointment.
Incidents Reported
During this time period 139 incidents were reported by staff on the incident reporting system. All
incidents are reviewed within a set period and are discussed monthly at the Clinical Unit team
meeting where individual incidents are discussed and any trends identified and actioned
accordingly. All staff are openly encouraged to report incidents and feedback is given.
41
Dermatology Quality Account 2012/13
Of the 139 incidents reported the top 5 themes are listed below; Patient Information (records,
documents, test results, scans), Access, Appointment, Admission, Transfer, Discharge, Consent,
Confidentiality or Communication, Accident that may result in personal injury, Clinical Assessment
(investigations, images and lab tests) and Treatment Procedure.
Clinical Outcomes
Skin Surgery - wound infection review
On average 354 patients a month are seen in Skin Surgery. There was a perception that the Unit
was seeing an increasing number of infections over a short period. On further investigation,
comparing monthly rates from the previous year, there had been a slight increase especially over
one month. The infections were all the same Staphylococcus Aureus (which is present in a third of
the population) and the infection rate for that particular month was 3.5% compared with an average
of 1% (the national average for skin surgery is 6%). All wounds were audited and the following
month the infection rate dropped to 1.3%. No apparent reason could be found for the sudden
increase but the Unit will continue to monitor and review rates monthly and have a threshold of
1.5%. The Unit has focused on: skin preparation times, hand washing techniques and implement
a change to patient letters to reflect hygiene prior to surgery, removal of make up and not to apply
creams or moisturiser on the day of surgery.
Quality Improvement Priorities for 2013/14
Quality
Domain
Best
Patient
Experience
Best
Clinical
Outcome
Our Quality Priorities
for 2013/14
Success Measures for 2013/14
Ensure clinic builds (appointment
slots) meet current requirements
and optimise waiting times
Patient and staff feedback.
Ensure pathway for on-call
patients is safe and appropriate
Patient and staff feedback
Safer surgery - focus on WHO
safety checklist and team
dynamics to prevent Never Events
New paperwork introduced and audited
Continued high level Dermatology
training
Trainees filling in favorable feedback for
the General Medical Council (GMC)
survey
Monitoring &
Reporting
Responsibilities
Clinical Governance &
Risk Management
Committee (CGRM)
Improve team working and leadership
skills
Continue to deliver research
WDUJHWVDQGPDLQWDLQ1RWWLQJKDP¶V
reputation for meeting these
nationally and continue to
maintain Comprehensive Local
Research Network (CLRN)
research portfolio
Maintain/improve position as 4 nationally
on the BADBIR (British Association of
Dermatologists Biologic Interventions
Register) and continue to maintain current
CLRN research portfolio with increased
numbers recruited
Consent in line with national best
practice and evidenced
Mental Capacity Act training for all clinical
staff (including healthcare assistants)
th
Clinical Governance &
Risk Management
Committee (CGRM)
Consent Audit
Most
Engaged
Staff
Improved communication within
the department
Regular meetings scheduled
Partnership sessions scheduled with staff
input into content
42
Clinical Governance &
Risk Management
Committee (CGRM)
Cardiology, Respiratory & Vascular
Quality Account 2012/13
About the Clinical Unit
We endeavour to provide a high quality service to patients ensuring that patients leave the Clinical
Unit with an understanding of their diagnosis and management plan. This is all provided in a safe,
compassionate and confidential environment by staff who are caring, professionally skilled and
dedicated to our patients.
Services Provided
The following services are provided within the Clinical Unit: Cardiology, Respiratory and Vascular
Clinics, Cardiac, Vascular and Lung Function testing, local anaesthetic vein treatments and ENT
(Ear, Nose and Throat) Sleep Service.
Achievement against Quality Improvement Objectives 2012/13
Quality Domain
Our Quality Priority for 2012/13
Outcome
Status
Patient Safety
Home visits to Non-Invasive Ventilation
(NIV) patients by specialist nurse in
order to reduce the number of
unnecessary hospital admissions
First stage NIV has started, a specialist
nurse currently works in house. This has
prevented unnecessary admissions to the
Acute Hospital Trusts.
Partially
Achieved
Patient
Experience
Transfer of appropriate Day Case
procedures to outpatient environment to
ensure that patients are safely and
efficiently treated
Trial of patients has taken place but
various reasons have prevented
progression
Partially
Achieved
Clinical
Effectiveness
Introduction of Abdominal Aortic
Aneurysm (AAA) screening programme
to ensure that the service is easily
accessible and regularly used by
patients
Patients are now screened in the
community and appropriately referred
following consultation to the Clinical Unit.
Creating a better pathway for the patient,
and refining the process
Achieved
Learning from Clinical Audits
The learning that has been implemented as a result of the clinical audits undertaken within the
Clinical Unit is as follows:
x
Home Ventilation Audit ± There is some evidence that unnecessary admission to hospital has
been prevented by the introduction of a specialist nurse to train patients. This audit is on-going.
x
Patients understanding diagnostics and pathway ± As part of a university project, this audit
demonstrated that most patients left the Unit with a good understanding of their diagnosis and
treatment plan. The audit highlighted the need for more patient information literature to be
available and this will be addressed.
x
Stockings after vein surgery ± This audit demonstrated that patients with an apple shaped body
may need made to measure hosiery and this has been implemented using a local UK
manufacturer.
43
Cardiology, Respiratory & Vascular
Quality Account 2012/13
Quality Review
Incidents
During 2012/13, our staff reported 199 incidents. Reporting incidents in the Clinical Unit is
encouraged as it allows the department to trend any themes, put suggestions forward for
improvements and learn from any mistakes or errors. All staff can report an incident, irrespective of
their grade or whether they are in an administration or clinical role. The Clinical Unit Team review
all the incidents on a monthly basis and ensure that appropriate actions are put in place to deal
with them. The data is shared with the whole department on a quarterly basis at our Best Practice
Sessions where there is an open forum to discuss the incidents which have been agreed and any
feedback on implementations which have been put in place. Our top 3 incident themes were:
x
x
x
Access, Appointment, Admission, Transfer, Discharge
Consent, Confidentiality or Communication
Patient Information (records, documents, test results, scans)
We have also used this information to feed into our Quality Improvement Priorities for 2013/14.
Patient Feedback
During 2012/13, the Clinical Unit received over 3500 feedback cards from our patients of which
98% of our patients who completed feedback cards would recommend us.
What we did well?
The majority (over 60%) of responses gave multiple aspects of their vists as an answer to this
question. More specifically Customer Care; Efficiency and Clinical Care.
³9HU\SOHDVDQWDQGTXLFNO\JLYHQLQVWUXFWLRQVDVWRZKHUHWRVLW$OOWKHVWDIIZHUHPRVWSOHDVDQW
DQGKHOSIXO´
³2QWLPHDSSRLQWPHQWDQGUHODWHGWHVWVPHDVXUHPHQW´
³'U;ZDVYHU\SOHDVDQW- friendly and professional. He spoke clearly and slowly which enabled me
WRXQGHUVWDQGDQGWDNHLQZKDWKHVDLG´
What could we have done better?
The majority (over 85%) of responses did not detail anything as an answer to this question. More
specific answers included Efficiency, Environment and Communication.
You Said:
We Did:
We received various comments about waiting
times to be seen when attending the
Treatment Centre
Some of our patients require additional tests that are often required
during their visit. We try to anticipate these tests prior to attendance
so staffing levels can cope with the demand, but unfortunately delays
do sometimes occur.
We received various comments about the
second waiting room - hot drinks on offer and
the machine being out of order as well as the
television in there not being large enough
We try to keep all patients informed of waiting times ± either in person
of via the television screens.
We continually monitor waiting times in clinics and feedback to
consultants about adhering to booked appointment times where
appropriate.
Earlier in the year; Gateway B piloted a new coffee machine. The pilot
has been successful and the coffee machines have now been rolled
out across the Treatment Centre. The machine in the Gateway B
waiting area has its contents checked twice daily by the
44
Cardiology, Respiratory & Vascular
Quality Account 2012/13
housekeepers and any issues throughout the day are picked up by
nursing staff.
We have now seen a reduction in the number of negative comments
relating to availability of drinks.
Lack of patient awareness about the CPAP
(continuous positive airway pressure)
maintenance programme:
³6XUSULVHGWKRXJKWREHWROGWKDW,UHDOO\RXJKW
to bring my CPAP in for service annually. Not
been said to me before and not been in for 7
\HDUV´
:HKDYHUHSODFHGWKH´WHOHYLVLRQLQWKHZDLWLQJDUHDZLWKD´
television, which now shows the waiting times as well as BBC News
24 and specific Treatment Centre information on rotation (subtitles no
sound). We have had positive feedback about this change.
We improved communication with our patients regarding
maintenance and servicing of their home ventilation machines.
Credit card size contact details provided to every patient (new and
current). Larger size contact details provided as standard with all new
ventilation machines (in the machine bag) as well as labels added to
the machines advising of the date which their machine will require a
free check.
We have ensured that maintenance staff are available on a daily
basis for patients bringing machines in, so they can be serviced while
they wait.
Quality Improvement Priorities for 2013/14
Quality
Domain
Best
Patient
Experience
Our Quality Priorities for 2013/14
Success Measures for 2013/14
Audit of patient¶s understanding of
their diagnosis
Ensure 100% of patients have good
understanding of diagnosis when
leaving clinic
Decrease waiting time from referral
to appointment for patients
Audit to demonstrated a 25%
reduction in average waiting times
Ensure waiting times are kept to a
minimum and any delays are
communicated effectively to
patients
Success would be measured by a
decline in comments on waiting
times on the feedback cards
Run an effective patient led home
ventilation support group for
Respiratory patients
Attendance by at least 6 patients to
3 meetings in the year
Monitoring & Reporting
Responsibilities
Clinical Governance Risk
Management Committee
(CGRM)
Terms of references and
expectations of group to be
documented
Best
Clinical
Outcome
Most
Engaged
Staff
Coordination of home visits for NonInvasive Ventilation (NIV)
Patients regularly accessing the
service and the reduction of
unnecessary attendances
90% of patients will have a
recorded diagnosis on the day of
treatment
Results reviewed from a 2 week
audit of all patients
Joint approach towards medical
notes between nursing staff and
administration staff
All staff fully aware and supportive
of medical notes process
45
Clinical Governance Risk
Management Committee
(CGRM)
Clinical Governance Risk
Management Committee
(CGRM)
Radiology Quality Account 2012/13
About the Clinical Unit
Radiology Services are situated in Gateway C of the Nottingham NHS Treatment Centre and
provide a valuable and highly efficient diagnostic service to all Clinical Units. We provide access
to a range of diagnostic services which are outlined below. We aim to provide a timely and high
quality service to all of our patients, ensuring their privacy and dignity is maintained at all times,
and that they receive the best possible service in preparation for future treatments.
Gateway C regularly provide support to Gateway D - Orthopaedics, on a Tuesday and Thursday
evening, by offering a direct access plain-film x-ray service to their new patients. This is accessed
by patients upon arrival at the Clinical Unit and allows the x-ray results to be viewed by the
FOLQLFLDQVDWWKHSDWLHQW¶V initial consultation, thus speeding up the patient pathway and the
treatment on offer to the patient.
Services Provided
MRI (Magnetic Resonance Imaging),, X-Rays, CT (Computerised Tomography),, Ultrasound,
Fluoroscopy for interventional cases.
Achievement against Quality Improvement Objectives 2012/13
Quality Domain
Patient Safety
Our Quality Priority for
2012/13
Outcome
Status
To identify potential risks and
implement change by
learning from incidents,
when these have occurred
We actively encourage incident reporting in an
open and transparent manner.
Partially
Achieved
Patient Experience
Implementation of Privacy &
Dignity action plans
We surveyed our patients¶ feelings towards privacy
and dignity to use as a baseline to work from. We
changed from gowns to using a 2 piece outfit. We
then surveyed our patients again and they agreed
that it improved their privacy and dignity. We are
exploring options to improve the waiting
environment for changed patients.
Partially
Achieved
Clinical
Effectiveness
To seek opportunities to
improve all aspects of our
service and learn from any
incidents to ensure better
patient experience and
outcomes
The Gateway has started to put information on the
TV screens relating to waiting times.
Achieved
Learning from incidents includes active questioning
of patients prior to imaging to ensure that the
correct examination is undertaken and to reduce
the risk of unintended radiation exposure.
Improved the quality of our patient information
leaflets for example extended medical criteria for
MRI alerts.
Extended entertainment options for patients
waiting for and during scans.
We have increased the interactions between the
different staff groups on the Gateway - admin,
Radiographers and Radiologists to ensure that CT
and MRI patient appointment times are booked in
accordance with patient needs and are clinical
appropriate. This has reduced waiting times on the
day for patients.
46
Radiology Quality Account 2012/13
Learning from Clinical Audits
The learning that has been implemented as a result of the clinical audits undertaken within the
Clinical Unit is as follows:
x Cannulation Audit ± Provisional analysis has confirmed a continued high success rate for
cannulation by radiographers, in line with correct protocols.
x Paper vs. E-requesting - Monthly audits have shown variation in requesting across the
Treatment Centre. The findings demonstrate that some areas are now requesting 90% of their
scans electronically. This is shared at the Executive Board and recommendations made.
x Radiation Protection Audit ± This is a compliance audit against IRR 99 (Ionisation Radiation
Regulations) to ensure all the practices of the department are complying with the legislation.
There is rolling 5 year programme which covers all the necessary areas under review.
Quality Review
Incidents
Between the 1 April 2012 and 31 March 2013, Gateway C had 68 incidents reported by staff on the
indicent reporting system.
Reporting incidents in the department is encouraged as it allows the department to trend any
themes, put suggestions forward for improvements and learn from any mistakes or errors. All staff
can report an incident, irrespective of their grade or whether they are in an admin or clinical role.
The Clinical Unit Team review all the incidents on a monthly basis and ensure that appriopriate
actions are put in place to deal with them. The data is shared with the whole department on a
quarterly basis at our Best Practise Sessions where there is an open forum to discuss the incidents
which have been agreed and any feedback on implementations which have been put in place.
The 68 incidents reported spanned many different areas, the broad themes of which were: Access,
Appointment, Admission, Transfer, Discharge, Clinical assessment (investigations, images and lab
tests), Consent, Confidentiality or Communication. Patient Information (records, documents, test
results, scans), Diagnosis, failed or delayed
We have reviewed these incidents in detail and where necessary completed a root cause
analaysis. It is not possible to go into detail on every incident, but an example of the changes to
the department following review of these incidents include:
x
x
x
x
x
Rebooking patient appointments to a more convenient time in cases where the offered
appointment was unsuitable.
Requesting changes to the Radiologists¶ new contract from August 2013 to ensure that
someone is always on site to support the correct patient protocol when this is not done in
advance. This reduces the potential wait when the patient arrives.
Ensuring that any findings from scans which are deemed urgent by the Radiologists are
escaODWHGWKURXJKWKHFRUUHFWµRAD DOHUW¶(radiology alert) process.
Confirmation with administration staff of booking procedures to ensure that patients have
the correct amount of time for their scan and a minimal wait.
Confirmation with staff on reporting procedures for repairing of machines to ensure they are
esclated in an efficient manner and patients are not adversely affected by any repairs.
Patient Feedback
Feedback cards, like incident reporting in the department, are encouraged as this allows the
department to truly understand what the patients want from their visit. We encourage staff to ask
all patients to complete a feedback card after their visit. As with the incident data, the Clinical Unit
Team review all the patient feedback cards on a monthly basis and ensure that appriopriate
47
Radiology Quality Account 2012/13
actions are put in place to address any suggestions or feedback. The feedback data is shared with
the whole department on a monthly basis and like the incident data discussed quarterly at the
partnership events.
During this time period, Gateway C received over 2500 feedback cards from our patients.
98% of our patients who completed a feedback cards stated they would recommend us and we
had a Net Promoter Score of 78%.
What we did well?
The majority (over 50%) of responses gave multiple aspects of their visits as an answer to this
question. More specifically Customer Care; Efficiency and Clinical Care. Comments included:
"Everyone was very helpful and open about all subjects. I was put completely at ease"
"Efficient booking in and speedy service"
"Good consultation Friendly - explained what was going on"
What could we have done better?
The majority (over 70%) of responses did not detail anything as an answer to this question. More
specific answers included the Environment, Efficiency and Communication.
You Said:
We Did:
"The only criticism I have is that there is no
sign indicating a toilet"
We have reviewed all signage in the department and have changed /
removed / altered to make the environment easier to navigate round.
In particular on the MRI and CT corridor we have added a hanging
sign from the ceiling indicating the toilet so this can be seen from
further away.
"Have a seating area. I was in my gown
awaiting CT and not very nice when reception
staff walking up and down [the corridor]"
Following several comments about privacy and dignity whilst awaiting
MRI and CTs, we have:
* Surveyed our patients¶ feelings towards privacy and dignity to use
as a baseline to work from
* Changed from gowns to using a 2 piece outfit. We then surveyed
our patients again and they agreed that it improved their privacy and
dignity (so we have kept these permanently)
* Commenced trialling separate female and male waiting rooms,
away from the original corridor waiting areas
Various comments regarding noise and music
options during MRI scan
Extended the choice of music CDs available to patients
Feedback to Radiographers that they need to give clearer instructions
about how patients can interact during their scan if not happy with the
level of music (press intercom button to speak to Radiographers)
Ensured that patient information given prior to MRI contains details
regarding the level of noise and the use of music to help with patients
expectations
To ensure that we have picked up all the comments provided - either through incidents, patient
feedback cards, complaints, comments or complements we have re-reviewed all of these and
added any outstanding ones to our quality improvement priorities for 2013/14 (see below).
48
Radiology Quality Account 2012/13
Quality Improvement Priorities for 2013/14
The priorities which the department would like to focus on for 2013/14 are:
Quality
Domain
Best Patient
Experience
Our Quality Priorities for 2013/14
Success Measures for 2013/14
Provide separate waiting areas for
men and women and ensure the
department complies with Privacy
and Dignity legislation
Re-survey patients after implementation
of new waiting areas to see if
satisfaction against previous survey
results has improved.
Improve the amount of information
displayed around the department
on the history of all the scans and
what patients can expect from their
treatment today, including a patient
pathway in pictures to be displayed
on the TV screens
Positive feedback from patient feedback
cards on waiting area environment and
information provided on what is
happening to them today.
Continue to reduce patient waiting
times - both for pre-booked
appointments and walk round
appointments
Use patient system to audit difference
between arrival times and scan start
time - success would be indicated by a
reduction over time.
Monitoring &
Reporting
Responsibilities
Clinical Governance
& Risk Management
Committee (CGRM)
Positive feedback on waiting times from
feedback cards
Best Clinical
Outcome
Most
Engaged
Staff
Carry out an audit on the accuracy
of requesting and reporting of Xrays for Orthopaedic patients to
comply with the Ionising Radiation
(Medical Exposure) Regulations
(IRMER)
Audits carried out on 2 x 50 patients at
different times of the year and results
feedback to staff that are not adhering to
regulations.
Success would be measured by an
increase in compliance between the
audits
Increase patient capacity by
extending operational working
hours
Reduced waiting times and adherence
to 2 and 4 week waiting times
Employ a direct hire, full-time
Radiology Lead / Manager to
oversee the operations of the
department.
Bring administration team in house
More cohesive and efficiently run
service which works better for the
patient
Bring Radiography helpers in
house
Clinical Governance
& Risk Management
Committee (CGRM)
Streamline admin processes
Expand size of team and spectrum of
duties to better meet the needs of the
service
49
Clinical Governance
& Risk Management
Committee (CGRM)
Orthopaedic Quality Account 2012/13
About the Clinical Unit
The Orthopaedics Clinical Unit is situated within Gateway D of the Nottingham NHS Treatment
Centre. We provide a large number of services as outlined below. We strive, as a team, to
support all patients with their individual needs, especially with regard to mobility due to the nature
of the speciality. We are unique in the fact that we are positioned adjacent to the diagnostic
department and also have the physiotherapy and occupational therapy team within the Unit, this
helps us to provide a one stop service to the majority of our patients. We also offer a wide range of
evening and weekend appointments to give patients a variety of choice. We have a close working
relationship with the day case department to ensure our patients have a smooth pathway both pre
and post operatively. We treat all patients as individuals, respecting their privacy and dignity at all
times.
Services Provided
Foot and Ankle Outpatient service, Hand and Wrist Outpatient service, Shoulder and Elbow
Outpatient Service, Hip and Knee Outpatient Service, Hip Revision Outpatient Service, Sports
Medicine, Physiotherapy, Nurse Specialist service providing advice on Day Case and long term
follow ups, Podiatry, Soft Tissue Disorders, Occupational Therapy, Acute Pain Service.
Achievement against Quality Improvement Objectives 2012/13
Quality Domain
Patient Safety
Patient Experience
Clinical
Effectiveness
Our Quality Priority for
2012/13
Ensure patients receive
their appointments in a
timely manner to reduce
the number of complaints
Look to re-introduce the
patient pager systems to
improve patient
confidentiality and net
promoter score
Improve the medical
records availability to the
gateway. The
administration and
nursing team met on 4
occasions to try to find a
way where the roles could
cross over and work
better
Outcome
Status
Staff have been given extra training to
emphasize the point of sending patients
information in a timely manner. Staff
are to call the patient to clarify the
appointment should an appointment be
made within that week. A confirmation
caller has been appointed,
communicating on a daily basis with the
Unit to update them on patient
availability and this has reduced any
confusion over appointment times and
dates from a patient perspective
Gateway has seen a
reduction in complaints
regarding appointments
in 2012-2013
The reception team is now actively
asking all patients if they would like to
take a patient pager to allow us to
improve patient confidentiality and also
to allow the patient to visit the atrium or
bathroom without them worrying about
missing their appointment
Since we introduced the
patient pagers we have
had no poor feedback
with regards this issue
The medical records are now kept with
WKHQXUVLQJWHDPEHKLQGWKHQXUVH¶V
station. This improves patient
confidentiality as the medical records
are no longer on show in the reception
area
We have seen a
reduction in incidents
reported where medical
records are missing;
however we have seen
an increase in incidents
reported with regards to
the accuracy of what
information that is in the
medical records
Nurses now prepare the medical
records for the clinics, a day in
advance, with the support of the
administration team. There have been
improvements in the availability of the
medical records. This structure allows
nurses to take control and manage
clinics to enable the patient to have a
better experience
50
Achieved
Achieved
Achieved
Orthopaedic Quality Account 2012/13
Learning from Clinical Audits
The Quickdash 6FRULQJ&DUSDO7XQQHODXGLWLVDQDQQXDODXGLWFDUULHGRXWWRDVVHVVWKHSDWLHQW¶V
improvement to life following the procedure. Results have indicated patients have seen an
improvement to lives. The audit will be carried out in 2013/14. Additional to this audit the team will
also be reviewing patients 6 months after the surgery, for an insight into the improvements they
have made and the condition of their hands following surgery.
Invasive reports carried out in 2012/13 have given the team a baseline to develop further audits in
2013/14. The results from these audits will be used to benchmark the invasive fixations,
medications and anaesthesia used.
Quality Review
Incidents
During 2012/13 our staff reported 138 incidents. All incidents are reviewed by the Clinical Unit
team at the monthly governance meeting. From the incidents reported the top three themes are:
x Access, Appointment, Admission, Transfer & Discharge
x Patient Information (records, documents, test results, scans)
x Consent, Confidentiality or Communication
The main aspects from the themes above involve patient appointments, providing information on
the appointments and communicating this to patients. The late cancellation of clinics from
clinicians has been the main cause of the disruption to our patients¶ care. The Clinical Unit team
has been challenging all requests that are received under 6 ZHHNV¶QRWLFH. If there is a genuine
reason for the cancellation the clinicians will be asked to move their patients to an alternative clinic
to ensure the patient needs are met. We are notifying patients immediately by phone and
rearranging their appointments for them. Following this, a letter confirming the change in the
appointment is sent out to all patients affected.
Our clinical lead has been very supportive and has spoken with individual clinicians who have
arrived late for clinic, causing delays to patients. Since the lateness of clinics has been discussed
we have seen a marked improvement to clinic times, and have noted the decline of incidents
reported of this nature.
Compliments
Of the compliments received over 2012/13 the main theme is the professionalism and the caring
approach from our team. One patient informed us that during an outpatient appointment for her
hand the registrar noticed the ladies eye looked sore and advised she went straight to eye
casualty, from investigation the lady was informed if she had not acted as quickly as she had she
could have lost the sight in this eye. This is an excellent example of how our team go the extra mile
to ensure patients receive all round care.
Patient Feedback
In 2012/13 we received 2,877 responses from our patient in regards to feedback. The top three
themes of which our patients consider we do well are; multiple aspects of their visit, Customer
care, and Waiting times.
We also ask patients and visitors to inform us of what we could have done better. The top three
themes noted were; waiting times, Communication and Information.
51
Orthopaedic Quality Account 2012/13
You Said:
Efficiency - Waiting times
" Keep appointment times
to correct times, not run
late"
We Did:
Examples of work undertaken to address waiting times:
x Updating of television screens
x By the nursing team working more closely with reception they have allowed the
reception staff to proactively monitor the clinic delays and inform patients as they
book in. Buzzers are then offered.
Communication
" Calling names - difficult
to hear"
Examples of work undertaken to address communication:
x Reintroduced the buzzer system which allows patients to sit anywhere in the
Treatment Centre, and be alerted to their appointment taking place
x One patient escorted at any one time into clinic area by the nursing team.
Examples of work undertaken to address information:
x As a hand team, we have developed an informative guide for patients undergoing
hand surgery. This is shared and explained with the patient at the time of listing them
for surgery. This helps them to understand and be prepared for their surgery.
x As a shoulder unit we have developed post-operative patient information sheets, to
help support with post-operative care and rehabilitation.
Information
" Provide better
information about what
will be involved at an
appointment"
Quality Improvement Priorities for 2013/14
Quality
Domain
Best
Patient
Experience
Best
Clinical
Outcome
Most
Engaged
Staff
Our Quality Priorities for 2013/14
Success Measures for 2013/14
Extend preoperative assessment availability
Reduction in number of
patients who have to come
back for their pre assessment
Pre assessment is held in the Gateway,
supported by staff trained and competent in
venepuncture and recording of ECGs
Increased number of patients
who have a one stop process,
consultation, pre assessment
and investigations
Develop a pathway that reduces the time
patients wait for MRI, CT and Ultrasound
scans and return to clinic for their results
All patients have scans and
receive results within 4 weeks
All pre-operative assessment for hand
patients is undertaken in this building to
ensure a one stop pathway
Patients have a one stop
pathway
Acute pain service to be commenced in the
gateway, to provide GPs fast access to a
Consultant regarding patients they are
concerned about
Number of patients seen
increases
Nursing staff to become competent at
applying casts for patients
Nurses have completed a
training package and are
maintaining competence
Administration and nursing staff to spend
All staff have spent time
WLPHXQGHUVWDQGLQJHDFKRWKHU¶VUROHVLQWKH learning about various roles
patient¶s journey
Nursing staff to complete a competency
framework that allows them to individually
care for patients post hand surgery,
following guidelines and protocols, reducing
the need for patients to see medical staff
Patients who have hand
surgery are seen by the most
appropriate person at the right
time
52
Monitoring & Reporting
Responsibilities
Clinical Governance &
Risk Management
Committee (CGRM)
Clinical Governance &
Risk Management
Committee (CGRM)
Clinical Governance &
Risk Management
Committee (CGRM)
Endocrinology & Rheumatology
Quality Account 2012/13
About the Clinical Unit
The Endocrinology & Rheumatology Clinical Unit can be found in Gateway E. The unit team aim to
provide all patients with a service that maintains their privacy and dignity, and cares for them as an
individual.
Services Provided
Rheumatology
Rheumatology is a clinical specialty dedicated to the care of patients with arthritis and related
disorders. The clinical workload is varied and includes disorders of the joints, bones, muscles and
soft tissues. In order to best support our patients there is a strong emphasis on team working
between doctors, nurses and allied health professionals. The management of rheumatic disease
has benefitted from this multi-disciplinary approach, and close working relationships with other
medical and surgical specialties has assisted us in improving our patients¶ quality of life. The
Rheumatology service is delivered by 8 consultants and 4 nurse specialists.
The consultants provide individual areas of expertise which include: Rheumatoid Disease,
Connective tissue disorders (lupus, scleroderma myositis), Ankylosing Spondylitis, Psoriatic
arthritis, Reactive arthritis, Vasculitis, Polymyalgia Rheumatica, Crystal arthritis (gout, calcium
pyrophosphate arthropathy),, Osteoporosis, Osteoarthritis, Fibromyalgia, Regional Soft tissue
Rheumatic Disorders, Ultrasound guided injections
We provide new patient appointments with diagnostic facilities including detailed blood tests and
imaging. Patients are followed up and treated according to clinical need and seen promptly when
necessary. Nurse specialists provide additional education, support and monitoring of treatment.
Endocrinology
Endocrinology is the specialty that deals with diseases affecting the endocrine glands of the body
and as such the hormones they produce. These include the thyroid gland, the adrenal glands, the
ovaries or testes and the pituitary gland. Investigating such conditions involves measurement of
hormone levels in the blood stream (blood tests) and diagnostic imaging such as thyroid ultrasound
scans or pituitary MRI scans. To provide patients with additional choice we offer appointments in
the evenings and on Saturday mornings.
The service is provided by a dedicated team of 7 consultants and 2 nurse specialists who provide a
range of services such as; assessment of secondary causes of Hypertension, Osteoporosis and
other metabolic bone disorders, Thyroid nodule clinic, Transition clinics for patients with Turner
Syndrome and for other patients moving from paediatric to adult services who have endocrine
disorders, joint clinics with Gynaecology, hormonal management of gender re-assignment patients,
nurse led infusion clinics, and nurse led telephone clinic.
We provide education and support to patients with adrenal insufficiency in the form of a patient
support group, and we have developed a range of patient friendly information leaflets covering a
range of endocrine disorders. We support colleagues in primary care who request written advice
and guidance using the Choose and Book appointment system.
53
Endocrinology & Rheumatology
Quality Account 2012/13
Achievement against Quality Improvement Objectives 2012/13
Quality
Domain
Patient Safety
Our Quality
Priority for
2012/13
All
investigations
requested are
processed
Outcome
The clinicians now place patient labels with the test request.
This reduces transcribing errors. We have seen the
rejection of samples greatly reduce
Staff are being trained to undertake phlebotomy to support
patients.
Patient
Experience
Patient
pathway
through clinic
The administration staff and Consultants have reviewed the
clinic structure and now have clinic sessions that provide
realistic appointment slots for their patients
Status
Achieved
Partially
Achieved number of staff
trained to be
increased
Achieved
Patient feedback over recent months has shown that
patients are satisfied with the journey through clinic. 99.5%
of patient and visitors who have attended the Unit would
recommend us
Clinical
Effectiveness
Booking
process ± to
establish a
robust system
that leads to a
reduction in
negative
feedback and
incidents
occurring
The nursing and administration teams have worked closely
in reviewing referrals to ensure patients receive
appointments within the required timescales
Achieved
Any appointments changes are confirmed with a direct
conversation with the patient and followed by a confirmation
letter sent
Learning from Clinical Audits
The learning that has been implemented as a result of the clinical audits undertaken within the
Clinical Unit is as follows:
x
x
x
x
Vaccination in Inflammatory Rheumatic conditions - This audit confirmed that the
Rheumatology team are recommending appropriate vaccination to protect patients with
inflammatory disease from influenza and pneumococcus.
Biologics in Non NICE indications - The audit of 69 patients demonstrated that patients with
vasculitis and connective tissue disease are treated appropriately with Rituximab. The
recommendations from the audit included that specialist disease activity scores continue to be
recorded and that individual cases are discussed among the group of Rheumatologists so that
consensus on management is achieved.
Compliance with British Thoracic Society Guidelines (BTS)/Tuberculosis (TB) guidance - This
audit demonstrated 90% compliance with BTS 2005 guidance. Recommendation points clarification on which patients should be referred to the respiratory team, agreed maximum
interval between chest radiographs and a clearer definition of which countries are at risk of TB.
Audit of recording Disease Activity Scores (DAS) for Rheumatoid Arthritis monitoring - This
audit showed a significant improvement in the recording of DAS scores in rheumatoid arthritis.
The compliance was 50% overall but much better in patients with a requirement to document
the DAS score for NICE approved drug therapies.
54
Endocrinology & Rheumatology
Quality Account 2012/13
Quality Review
Concerns & Complaints
We have reviewed all complaints, concerns and comments and the most common theme relates to
information not being given in a considerate manner, primarily by the medical staff. Many of the
disorders treated by Rheumatology and Endocrinology are not easily diagnosed and a SDWLHQW¶V
weight can directly affect their management and outcome. It is necessary to inform patients that
their weight is affecting the quality of life and that regular exercise is required. Patients have
reported that this news has not been given in a kind or sympathetic manner. We have therefore
ensured that the clinicians are given this feedback immediately in order to learn from and improve
communication skills. We have also used such examples in the gateway partnership sessions to
learn ways of discussing news that patients may not want to hear. It has been valuable to have
real examples to share.
Incidents
We have an excellent reporting culture and staff have reported 197 incidents. The most common
themes have been; appointment errors, incorrect bookings, patients not aware of changes to
appointments, and over booking of clinics. The administration team have worked hard on these
areas and have spoken with all the clinicians about their clinic scheduling requirements. They now
call all patients whose appointments need to be changed and only book and send out an
appointment if they have tried on 3 occasions to contact them. Whenever possible an appointment
is booked either on the day or after a telephone conversation. The team have also developed new
partial booking codes to give them the confidence that the patients are booked into the correct
clinic.
Patient Feedback
We asked 1788 patients for their views. The main themes suggested as improvements are below
with how we have resolved some of those issues.
You Said:
Efficiency - Waiting times
³/RQJZDLWWREHVHHQE\
doctor."
Information
³0DNHOHDIOHWVHDVLHUWR
get. Helped by staff so got
what needed."
Communication
" Call day before or text to
remind of appointment"
We Did:
Examples of work undertaken to address waiting times:
x Consultants have reviewed booking rules and set up clinic sessions with an
achievable number of appointment slots
x Feedback over recent months has shown that patients are satisfied with the
journey through clinic
Examples of work undertaken to address information:
x We have increased the range of information leaflets available to patients
x Lifestyle leaflets are in the waiting area, disease specific information is available for
the clinicians to give as needed
x More staff have been trained in ordering the leaflets and restocking
Examples of work undertaken to address communication:
x As with the entire Treatment Centre we have a confirmation caller in post
supported by the administration team to remind patients of appointments
x We are waiting the go live of text reminders
Quality Improvement Priorities for 2013/14
Quality
Domain
Best Patient
Experience
Success Measures for
2013/14
Our Quality Priorities for 2013/14
1. Community clinics.
(a) Identify subgroups of patients who can be
managed safely and effectively close to their
own home.
(b) Establish the community clinic and resource
this appropriately according to patient needs.
(c) Assess patient satisfaction with the delivery
of community clinics.
55
We have at least one clinic
for rheumatology in a
community setting within 12
months
Monitoring &
Reporting
Responsibilities
Clinical
Governance &
Risk
Management
Committee
(CGRM)
Endocrinology & Rheumatology
Quality Account 2012/13
Best Clinical
Outcome
Most
Engaged
Staff
2. Provide the patients having therapy for
osteoporosis a one stop service in the Treatment
Centre
Consultations,
investigations and
treatments are all conducted
at the Treatment Centre
3. New to appropriate follow up ratios
(a) Establish appropriate new to follow up ratios
according to case-mix to ensure new patients
can be seen promptly (approx. 4:1)
(b) Follow up patients appropriately according to
national guidance and clinical need
(c)Establish pathways to identify patients who
can be managed for follow up in primary care or
reviewed in nurse clinics and by telephone
consultation
4. Patients will be involved in a cycle of feedback
on their appointment, understanding of
treatment options, and clinic letter
Reduction in wait time for
new patients having a first
consultation. Follow up
appointments are seen by
the professional most
relevant to the stage of their
treatment
5. Multisystem disease management
(a) Create dedicated clinic for patients with
multi-system disease staffed by specialist
consultants (PCL/PC3)
(b) Improve access to other specialists with
improved interdisciplinary management and
access to other specialists
6. Ultrasound
(a)Provide ultrasound assessments for patients
to objectively demonstrate successful treatment
to target in RA and achievement of remission.
(b) Provide ultrasound guided injections as
clinically indicated
(c) Assess patient satisfaction with delivery of
ultrasound assessments and guided procedures.
(d) Contribute to teaching and training
programme in ultrasound nationally
7. Staff will be trained to undertake
venepuncture to support the out of hours clinics
The number of follow up
appointments with several
clinicians and specialties
will be reduced
8. Staff are to be supported with training that
extends their roles, giving them more
satisfaction in their role
All staff will have had the
opportunity to learn a new
skill
9. Multi-skilling of nursing and administration
staff to provide in depth knowledge of patient
pathways. This will allow mutual understanding
of each other
All staff will have spent a
minimum of one day
working in the opposite
team
10. Research
(a) Establish Nottingham in the top 5 recruiting
centres in the UK for arthritis research
(b) Aim to offer the majority of patients the option
to take part in research as part of their standard
of care.
(c) Extend high quality research portfolios in the
fields of rheumatoid arthritis, osteoporosis,
connective tissue disease and vasculitis with
research grants and increased recruitment
Circle will have a paper
accepted for publishing a
research project. Staff will
have had feedback at
partnership session on the
research and changes that
have come about
56
Both specialties will have
had 2 rounds of 28 day
questionnaires
Audit will show an improved
patient pathway with quicker
diagnosis.
Clinical
Governance &
Risk
Management
Committee
(CGRM)
Enough staff are trained to
provide support for all
clinics, no patient has to
return for testing
Clinical
Governance &
Risk
Management
Committee
(CGRM)
Gynaecology Quality Account 2012/13
About the Clinical Unit
We are a unique team who endeavour to provide a safe, caring and empathic service to our
patients in a professionally skilled, confidential and compassionate environment. The clinical care
provided is Consultant led and supported by a team of experienced nurses and healthcare
assistantsDQH[FHOOHQWDGPLQLVWUDWLYHWHDPIDFLOLWDWHRXUFOLQLFDSSRLQWPHQWV:HSURPRWHDµRQH
VWRS¶DSSURDFKZKHUHSRVVLEOHLQFOXGLQJXOWUDVRXQGLQRUGHUWRHQVXUHWKDWZHSURYLGHWKHPRVW
convenient service to our patients. We also offer some appointments in a community clinic setting
to facilitate ease of access to our service. We are proud to be a teaching unit, we support General
Practitioner training and both medical and nursing students as well as junior doctors wishing to
specialise in the area of women's health.
Services Provided
Gynaecology services include general and suspected Cancer Outpatient Clinics, Menopause
Clinic, vulval skin disorder clinic and a range of services including continence investigations and
advice, unplanned pregnancy assessment, sterilisation and Dexa (Bone Mineral Densitometry)
scanning. Our Menstrual Disorders LQFOXGHDµRQHVtop¶ hysteroscopy service, endometrial ablation
and a uterine fibroid clinic.
Colposcopy service includes Post Coital Bleeding Clinic and a Nurse Led Smear Service.
Achievement against Quality Improvement Objectives 2012/13
Quality
Domain
Patient
Safety
Patient
Experience
Our Quality Priority for 2012/13
Outcome
Improve equipment provision
to ensure a reduction in need
to report incidents. Reduction
in the delay or cancellations of
appointments
There have been numerous surgical
instrumentation issues, However these have been
robustly reported and escalated, which
demonstrates a strong reporting culture in the
department. Disposable alternatives have been
sought which has mitigated any detrimental
effects to patient care and as a result, no patients
have had treatment cancelled
Achieved
Waiting Times:
An audit of waiting times was undertaken last
spring and as a result, The key clinics have been
redesigned to minimise waits. Designated
emergency slots have been allocated to allow for
such patients to be accommodated without
detrimental effect to the rest of the clinic. Patient
information has been reviewed and new items
included in the ± µ:HOFRPHWR*DWHZD\)¶ leaflet to
help explain the nature of the clinics and why
delays sometimes occur
Achieved
A 40% return rate of questionnaires and reported
results has been achieved
Achieved
x
x
x
Clinical
Effectiveness
Patients waiting no more
than 30 minutes from their
appointment time
Reduced number of
negative comments
Increased number of
positive comments
Review of clinical outcome
following ablation
Status
Learning from Clinical Audits
x
A nurse led smear clinic has been introduced to increase capacity in consultant led follow up
clinics and ensure patients are receiving the same level of excellent clinical care
x
The nurse led smear clinics have demonstrated that 100% of patients have had effective
samples taken and results returned
57
Gynaecology Quality Account 2012/13
Quality Review
Complaints & Concerns
We have reviewed all of our complaints and concerns and have identified the following themes.
Although we have addressed patient complaints and concerns during the year, we have also used
this information to feed into our Quality Improvement Priorities for 2013/14.
Theme
Appointments ±
delays/cancellation
s/rearrangements
Action Taken
We have worked hard with all colleagues to communicate efficiently and effectively to coordinate appointments, provide patient information about the clinic unit with new appointment
letters and use the communication forum Twitter WRLQIRUPSDWLHQWVDQGUHODWLYHVLQDµOLYH¶
format of the television.
Where we can, we telephone patients in advance if we are aware there are going to be delays
thus giving them opportunity to reschedule. This is not always possible when there are
unforeseen circumstances.
Communication
We have responded by understanding the concerns and communicating more effectively with
the General Practitioners.
Aspects of Clinical
Care
We have improved our patient information and sought to improve links with other Clinical
Units such as the Day Surgery Unit (Treatment Centre) and the Gynaecology short stay ward
and Gynaecology ward at the Acute Hospital Trust.
Patient Feedback
During 2012/13, we have had over 3000 feedback cards returned. Of these cards 98.8% of
patients said that they would recommend us to their friends and family. A number of patients wrote
to us about their experience in our Clinical Unit:
"My treatment was excellent. The doctors and nurses treated me with such kindness. I was very
impressed with the staff. Thank you so much for the treatment I received".
"I just wanted to say thank you so much for taking such great care of me while I was with you. You
were all so kind and were amazing at your jobs. I felt so looked after in your care. Thank you and
may God EOHVV\RXIRUDOOWKDW\RXGR´
You Said:
We Did:
x
x
That waiting time for clinic
appointments are too long
x
x
Not enough seating
Unable to hear when
name is called
x
x
We have looked at the clinic timings for clinics which we know can run late
We have re-organised these clinics to allow more time for patients by amending the
length of appointment slots
We have put the 'on-call' (urgent doctor requests) slots throughout the clinic and we
are not scheduling them at the start of the clinic which allows the clinic to run in a
more timely manner
We have rearranged the seating area and utilised the space more efficiently to allow
for extra seating
Patient pagers are offered to all patients so that they do not have to stand and wait
on the Clinical Unit, but are able to find seating elsewhere e.g. the Atrium our coffee
shop.
We offer the pagers to our patients so that they do not have to listen for their names
to be called. The pager will buzz and flash and let them know when we are ready for
them.
58
Gynaecology Quality Account 2012/13
Incidents
During 2012/13, our staff reported 163 incidents. Incidents are discussed monthly at the Clinical
Unit team meeting where any trends are identified and actioned accordingly. All staff are openly
encouraged to report incidents and feedback is given.
The two key trends identified through incident reporting have been:
x Effective return and provision of instrumentation from the sterilisation centre: The team have
worked closely with the sterilisation provider to ensure that instrumentation is efficiently and
effectively returned to the Treatment Centre. Disposable instrumentation has been sourced
and utilised to ensure that investigations and treatments are able to proceed.
x
Lack of information relating to patients¶ surgery at other hospitals: Work is ongoing to ensure
that other hospitals provide record regarding any surgical procedures undertaken in their facility
and these are available when patients are seen again at the Treatment Centre.
Quality Improvement Priorities for 2013/14
Quality
Domain
Best Patient
Experience
Best Clinical
Outcome
Most
Engaged
Staff
Our Quality Priorities for
2013/14
Success Measures for 2013/14
We will reduce negative
comments relating to waiting
times in the Clinical Unit
There will be a year-on-year reduction in
the quantity of negative comments relating
to waiting times on the feedback cards
We will reduce unnecessary
hospital attendance and
support care closer to home by
commencing a pilot of
Gynaecology clinics being held
within a community setting
We will undertake a review of services
provided year on year to identify where
the provision of care should be situated.
We will participate in
Colposcopy Quality Assurance
Peer Review
We will achieve positive feedback
following the peer review and develop an
action plan to address any outstanding
actions
We will establish a Staff Focus
Group aimed at improving the
overall service provision
We will achieve an increase in staff
named in patient feedback
We will establish a rapid cycle
staff survey and learn from the
feedback
We will increase staff satisfaction
throughout the year and demonstrate this
via re-audit
We will develop a Healthcare
Assistant training programme
We will have a sustainable, dedicated and
knowledgeable workforce within the
Clinical Unit
59
Monitoring &
Reporting
Responsibilities
Clinical Governance
& Risk Management
Committee (CGRM)
Clinical Governance
& Risk Management
Committee (CGRM)
Clinical Governance
& Risk Management
Committee (CGRM)
Day Case Quality Account 2012/13
About the Day Case Clinical Unit
The Day Case 8QLWLVYHU\PXFKµWKHKHDUW¶RIWKH7UHDWPHQW&HQWUHWe treated 12,066 patients
within the unit last year. We are able to provide holistic care to all our patients by offering preassessments at a time and location convenient to the patient. The number of patients attending on
the same day from clinics has increased from 33% to 84%. This is a positive outcome for the patients
as they are able to be seen on the same day and not have an extra visit to the Treatment Centre on
the day of surgery. Our ward area is used for first and second stage recovery allowing patients to be
treated with privacy, dignity and respect by nursing staff who are passionate about Day Case
Surgery. Last year the nursing staff LPSOHPHQWHG³+RXUO\5RXQGLQJ´ZKLFKKHOSVXVWRUHJXODUO\
assess individual patient needs. Patient feedback is positive regarding the improved communication
they receive whilst they are waiting for their procedures. We also aim to contact all patients within 24
hours of surgery, to confirm a satisfactory recovery and offer any necessary support.
In 2012/13 we introduced minimally invasive arthroscopic shoulder surgery. All of these patients are
treated using a regional anaesthetic block, which enables them to watch the procedure and have their
operative findings discussed with them during their surgery. Feedback to date from the patients has
been very positive.
A safety FDPSDLJQ³6top the Line´ was launched in the Treatment Centre in 2012 and the Day Case
Unit staff have been active in ensuring that this process is followed. This has enabled all relevant
personnel to get together and discuss issues that have occurred and jointly develop solutions. The
result is a continuous improvement process and changes are made to reduce the risk of recurrence.
The information is fed back to the staff through our regular Partnership training days, further
improving safety by sharing the learning. We also share learning with the public through our Circle
website.
Our partnership days occur on a two month cycle and are planned so that disruption to clinical activity
is minimal. This ensures most staff are able to attend without affecting patient care. We use these
sessions to discuss incident updates, feedback from patients, complaints or changes to our services.
This opportunity is also used for mandatory and scenario training sessions. Staff are given the
opportunity to identify learning opportunities that would benefit their personal and professional
development.
Our Patient Champion meetings continue with a member of the Patient and Public Engagement
Group attending. We have found their input valuable and aim to continue building this partnership.
The team felt that we could expand the opportunities to benefit from feedback with the introduction of
the concept 'Mystery Shopper'. This provides more in depth feedback by a pre-selected patient who
shares their observations with the staff at the Patient Champion group. The overall result is improved
service for all of our patients. In this way the Day Surgery Unit will continue to provide the highest
quality care, safely and efficiently in a patient centred fashion.
Services Provided
General Surgery, Gynaecology, Chronic Pain Treatments, Orthopaedics - Foot and Ankle, Hand,
Lower Limb, Shoulder Surgery, Maxillo-Facial Surgery, Urology, Podiatry, and Venesection services.
Achievement against Quality Improvement Objectives 2012/13
Quality
Domain
Patient
Safety
Our Quality
Priority for
2012/13
Aim to achieve
100%
compliance with
WHO safety
checklist
Outcome
Status
Regular monthly audits demonstrate compliance levels at each of
the three stages
Compliance is excellent at stage 1, however further work needs to
be undertaken to ensure that stages 2 (~95%) and 3 (~90%) are
also completed routinely
Partially
Achieved
60
Day Case Quality Account 2012/13
Patient
Experience
Ensure all
patients receive
optimum care
during their stay
The implementation of nurse hourly rounding has significantly
improved the patient experience
Achieved
The Mystery Shopper technique was trialed in March and provided
excellent detailed feedback with both positive comments and
suggestions for improvement
The Patient Focus newsletter was introduced which reports our
improvements and includHVD³\RXVDLGZHGLG´VHFWLRQ
A food and refreshments survey/audit was undertaken with
patients and as a result, a broader range of options including
cereals, cheese & biscuits and soups are now available for
patients after their treatment
A review of patient gowns was undertaken with disposable options
considered. The conclusion was to retain existing gowns
Clinical
Effectiveness
Reduce wait
times on the day
of surgery
leading to
increased patient
satisfaction
rates.
We have seen a decline in the number of comments about waiting
times in the Unit compared to last year. Staggered and phased
admissions have continued and developed further this year, which
has been welcomed by patients. The introduction of our
Admissions Lounge also means that patients can be admitted to a
comfortable area where they can remain clothed until necessary
and use the entertainment facilities
Reduce the
number of
complaints
regarding rushed
discharge.
There has been one complaint throughout the year relating to
rushed discharge which may have been as a result of increased
usage of our discharge lounge
Reporting
infection rates,
admission rates
and other
concerns,
complaints and
comments and
ensuring
infection rates
remain
negligible,
patient
satisfaction
remains
excellent and
that clinical
recovery is as
good as it can be
We contacted 70% of patients at 24 hours and 53.3% at 28 days
post operatively. This data provides valuable information
including patient satisfaction, and feedback on key outcome areas
such as infection rates, deep vein thrombosis, re-admissions and
pain levels
Patient satisfaction levels have remained consistently high at
99.7% with a Net Promoter Score of 77.5%
&DUHU¶V*XLGHLQIRUPDWLRQZDVLQWURGXFHGLQ-XO\ZKHUHZH
provide information for the carer including what happens on the
day and how best to contact the unit if they have any queries
Pain and post-operative nausea and vomiting (PONV) audit ±
shows that with increasing levels of complex surgery, patients are
experiencing higher levels of post-operative pain than 2 years ago
Achieved
Ongoing
review of
clinical
situation
Increased
availability for
stronger
analgesia is
now provided,
as well as antisickness
medication for
³WDNHKRPH´
prescription
Learning from Clinical Audits
The learning that has been implemented as a result of the clinical audits undertaken within the
Clinical Unit is as follows:
x Increased safety awareness with WHO check list audits
x Clinical recovery audits (including 24 hour and 28 day) resulted in improved treatment of skin
preparation for surgery, better analgesic regime employed and take home tablets for managing
nausea and vomiting
x Patient experience has been improved by use of patient feedback DQGHVSHFLDOO\WKH³0\VWHU\
SKRSSHU´LQIRUPDWLRQ
61
Day Case Quality Account 2012/13
x
x
Association for Peri-Operative Practice (AfPP) audits continue to demonstrate high clinical and
professional standards on the unit
Pre-Operative Assessment audits show that appropriate and timely assessment occurs for our
patients.
Quality Review
During our Patient Champion meetings we discuss the feedback received regarding the patient's stay.
We evaluate their comments to establish trends and review progress with improvement projects. We
identified patients were still waiting for some time in the reception area before accessing the ward. To
improve this, alterations were made within the unit to accommodate patients in an Admission Lounge.
Currently we use it for patients undergoing pain injections or those having Local Anaesthetic
procedures. This enables the nursing staff to commence the admission process earlier, therefore
reducing the patient¶s wait. The objective going forward is to utilise this area more effectively.
We have an excellent reporting culture and our staff have reported 719 incidents during 2012/13. The
Unit reviews all incidents monthly and by doing this identified patients cancelled on the day of surgery
as a recurring theme. We reviewed the patient cancellations and noticed a trend with patients who
had been seen in the community clinic not being fit for surgery. A pre-assessment process (to gain
more knowledge of patient needs) is now undertaken to address this; initially this was for local hand
surgery procedures but our objective is to extend this to all patients. Nursing staff now inform the
referring General Practitioner if a patient has had to be cancelled, should there be a reoccurring
problem.
We also noted via the incident reporting mechanism that there was a requirement to improve
communication between organisations where transfer to an inpatient bed was necessary due to
complications. We have made adjustments to the in-patient transfer communication sheet which will
facilitate a clear handover between both organisations, especially in relation to medicines the patient
has received during their stay. This has been approved by the Medicines Management Committee,
and already clinical changes such as improved analgesic regimes have addressed some of the
causes of a slow recovery.
Specific incidents have led to the introduction of emergency drills. One example was access to
emergency bloods with improvements being made to the process and training sessions being
implemented. Blood bank staff provided theory training which was followed by a practical
assessment. Regular emergency scenarios are undertaken, and staff are put through their paces
when they least expect it.
We access patient feedback in a variety of ways including the 24 hour/28 day follow up phone call,
complaints, concerns and comments received from patients and our favourite the 'Mystery Shopper'.
In our quest to constantly improve, we take all these comments very seriously and some issues and
responses are described in the table below:
You Said:
We Did:
Lack of provision for nursing
mothers
Lack of patient information
regarding bruising following
surgery
TV not working in the bay
We have purchased a nursing chair. This is situated in the Admission Lounge and can
be moved to the SDWLHQW¶V cubicle if required.
Production of patient information leaflet for wound care and updating existing
information to reflect possible complications
Lack of information regarding
who to call if there is a problem
once discharged
$GGLWLRQDOLQIRUPDWLRQDGGHGWRGLVFKDUJHOHWWHUSURGXFWLRQRI³SDWLHQWIRFXV´OHDIOHW
available in every patient cubicle. This provides information about the 24 hour and 28
day follow-up calls
We also inform patients about the WHO checklist, hourly rounding and staggered
arrivals
The ward area daily checks now includes functionality of TVs
62
Day Case Quality Account 2012/13
The food was too dry
Patient still felt in pain
The range of food offered has increased to include breakfast cereal, soup, rolls,
cheese and biscuits and sweet biscuits. There has also been an increase in the range
of beverages available.
A review of the medication provided and also an audit of the response at 28 days to
see if the medication prescribed met the patient's expectation
We have continually reviewed and acted on what our quality data has told us throughout the year,
and as such we have already made many service improvements benefitting both patients and staff.
We have developed our priorities for the forthcoming year knowing what our patients want,
comfortable in the knowledge that our staff are empowered and willing to improve services, and that
we have rapid access to quality data in order to monitor this.
Quality Improvement Priorities for 2013/14
Quality
Domain
Our Quality Priorities for
2013/14
Best
Patient
Experience
Introduce a dignity passport
into care pathway, reducing
incidents / comments relating
to social issues
,QWURGXFH³LQ-SDWLHQW´EHGVWR
enable improved postoperative care
Further improve patient Privacy and Dignity
aspects of care demonstrated by improved
feedback
Improve communication
methods to patients
Develop a video presentation about the Unit,
perhaps with availability on the internet.
Improve all aspects of the
patients pathway
Further improve patients experience by the use of
Mystery Shopper feedback
WHO safety checklist
compliance at stage 2 & 3
&RQWLQXHGDELOLW\WR³6top the
LLQH´LIVDIHW\FRQFHUQVDULVH
Monthly audits - aim for 95% compliance at all
stages
Promote a learning culture for safety grows and
continue active reporting of potential issues
Patient recommendations
and Net Promoter Scores
Aim for 100% patient recommends and 85% Net
Promoter Score
Improve patients,
consultants, anesthetist and
staff experience
Pre and post theatre session briefings pro-forma to
be adopted.
Information to be fed through Clinical Leadership
team and Patient Champion forum
Scenario training and
learning from incidents
through practical reenactment
Support of incident reporting
by staff
Continuation of a safety learning culture
Maintain staff working
conditions, ensuring time
keeping, breaks and work life
balance is maintained
Monthly staff surveys
Best
Clinical
Outcome
Most
Engaged
Staff
Success Measures for 2013/14
After care could include overnight stay if required
Increase scope of work within the unit and manage
post-operative patients more appropriately
(QDEOHPRUH³HQKDQFHGUHFRYHU\´SDWKZD\VWREH
established improving recovery following surgery
Ability for Unit to continue to learn from incidents
which affect patient care
63
Monitoring &
Reporting
Responsibilities
Clinical
Governance & Risk
Management
Committee (CGRM)
Clinical
Governance & Risk
Management
Committee (CGRM)
Clinical
Governance & Risk
Management
Committee (CGRM)
Endoscopy Quality Account 2012/13
About the Clinical Unit
In the Endoscopy team pride themselves on our ability to offer tailored education and
reassurance to each patient on an individual basis. Each staff member is encouraged to
have a voice in the improvements and developments of our service where we aim for all
patients to feel that they have been looked after by competent and knowledgeable
professionals who always them first.
We are very proud to have passed JAG Accreditation in 2012. This is a national award
given to Endoscopy Departments who reach a gold standard in various important aspects of
their service including patient experience, clinical quality, workforce and training. We are
now one of less than 10% of independent units in the UK to have achieved the award so far,
and we are aiming to ensure our excellent levels of care continue and are improved upon
year on year.
The Unit takes an active role training medical and surgical endoscopists along with
employing and training our own nurse endoscopists. We have been chosen as a hub for
Derby University student nurses providing in-depth gastroenterology education for one year
of their study. We are also undertaking various research studies in order to improve the
clinical care of our population for future generations.
National guidelines for Endoscopy units predict an increase in demand for our services, the
unit is responding to the needs of our patients by extending opening times to include
evenings and weekends.
The Endoscopy service is situated in Gateway H where we have delivered the best quality
care to approximately 10,000 patients in our state of the art suites equipped with a modern
high definition video endoscopy system. The Unit has a pre-assessment and telephone preassessment service, 8 admission rooms, separate male and female pre-procedure waiting
area, 2 enema rooms, a recovery area for 9 beds, a discharge lounge and 3 quiet rooms.
We have a live link from one procedure room in order to provide an excellent training facility
for nursing and medical staff. We also have on site decontamination facilities so that our
equipment can be sterilised quickly and efficiently. Care is delivered by 16 Endoscopists, 6
Nurse Endoscopists, 23 Nurses and 17 Healthcare Assistants who are supported by 7
Administration staff.
Services Provided
Colonoscopy, Flexible Sigmoidoscopy, Gastroscopy, Polyp Removal, Haemorrhoidal
Banding, Cystoscopy, Endoscopic Mucosal Resection for polyp removal, Varices Banding,
Bronchoscopy, GI luminal stricture dilatation, Argon beam ablation for the oesophagus,
Botox injection for achalasia of the oesophagus.
64
Endoscopy Quality Account 2012/13
Achievement against Quality Improvement Objectives 2012/13
Quality
Domain
Patient
Safety
Our Quality Priority for
2012/13
Improve Endoscopist training
experience and Endoscopy
Nurse education and
competencies
Outcome
The Unit now has a structured weekly
timetable for training lists with reduced
numbers of procedures to offer trainees a
structured and valuable training experience
Status
Achieved
A detailed annual timetable for all nursing staff
has been developed to embrace a variety of
educational courses and study days
Patient feedback shows we provide a
motivated, knowledgeable and highly skilled
workforce for every procedure undertaken
within the Unit
Patient
Experience
Redesign of unit to improve
patient flow and Privacy and
Dignity
The unit redesign has been completed with
same sex accommodation whilst improving on
the privacy, dignity and confidentiality for each
of our patients. This has been reflected on our
annual patient satisfaction survey results.
Achieved
Clinical
Effectiveness
Achieve JAG Accreditation: To
undertake an agreed annual
audit timetable to show
consistently high standards of
care can be maintained and
built upon year after year
We have successfully achieved JAG
Accreditation and are within < 10% of
independent sector providers to achieve this
award within the UK. We plan to aim higher
and achieve level A results by next year
Achieved
Learning from Clinical Audits
The learning that has been implemented as a result of the clinical audits undertaken within
the Clinical Unit is as follows:
x
x
x
x
Each individual endoscopist¶V audit results are sent to the Clinical Lead Clinician on a
six monthly basis to review and ensure that levels of practice are within national
guidelines.
The audits for repeat endoscopy for gastric ulcers and correct position of colonic
tumours ensures we are following best practice and patients receive the best care
possible at all times.
An annual patient survey is reviewed and an appropriate action plan developed, with
results acted upon within 3 months.
Bowel preparation is audited to ensure lower GI procedure produce the best possible
result.
Quality Review
As part of the JAG accreditation process we must ensure that we are delivering a quality
training environment for our trainee endoscopists. To gain a competitive advantage and
improve the quality of future recruitment we have decided to focus on gaining hub
placement recognition and as such this is a priority for 2013/14.
65
Endoscopy Quality Account 2012/13
We recorded 203 incidents over the time period in question and one Stop the Line. In
2012/13 three bowel perforation incidents were reported, as such we have decided to
prioritise this issue for 2013/14 by changing our bowel inflation substance to carbon dioxide
as it is more readily absorbed by the bowel wall.
We have listened to what you have told us with 2,767 patients providing us with feedback,
400 of those were suggestions on how we could make improvements to our services. We
have seen recurring comments regarding appointment waiting times, and have used this
information to prioritise this issue for 2013/14 by piloting the use of Entonox as a sedation
due to its shorter discharge timeframe.
You Said:
That waiting time for
clinic appointments
is too long
Patient information
leaflets are
complicated and
difficult to read
Lack of
communication
following procedure
We Did:
Examples of work undertaken to address waiting times:
x All Endoscopists are now contacted 20 minutes after their start time if they do not
arrive on time for their list
x We now have boards in the internal waiting rooms displaying each morning and
afternoon endoscopy lists. These are updated regularly to keep patients informed
of delays as they occur
x The nurses are working with the administration team to regularly validate the
procedure lists to ensure the patients are provided with the suitable amount of time
for their procedure
We have now changed the patient information leaflets to ensure patients find them
easier to understand, with clearer and concise guidance on how to prepare for lower
GI investigations
We have now developed better links with the Nurse Specialists to ensure the required
patient referrals take place on the same day
Quality Improvement Priorities for 2013/14
Quality
Domain
Best
Patient
Experience
Our Quality Priorities for
2013/14
Undertake a pilot study of
Entonox use for sedation
and analgesia within the
Endoscopy unit
Best
Clinical
Outcome
Change practice to use
carbon dioxide inflation of
the bowel for lower
Gastrointestinal
procedures rather than
using air.
Reduction in complications following
lower Gastrointestinal procedures,
including reduced discomfort and
recovery time
Most
Engaged
Staff
Become a placement hub
where student nurses are
linked to the Treatment
Centre for one year of
their training.
We will gain hub placement recognition,
continued mentorship training for our
nurses and provide an excellent
placement and learning opportunities for
student nurses.
Success Measures for 2013/14
The pilot study will show this is
beneficial to the patients as a suitable
alternative to the intravenous sedation
and analgesia offered at present
Capture feedback from students
66
Monitoring & Reporting
Responsibilities
Clinical Governance &
Risk Management
Committee (CGRM)
Clinical Governance &
Risk Management
Committee (CGRM)
Clinical Governance &
Risk Management
Committee (CGRM)
Digestive Diseases Quality Account 2012/13
About the Clinical Unit
The Digestive Diseases and Urology outpatient department provide safe, professional and discreet
care to approximately 25,000 patients each year who have presented with health concerns of a
sensitive nature. We provide access to a range of interlinked specialties which are outlined below.
Our staff are committed to ensure that each patient is treated as an individual, with respect,
compassion and dignity, to ensure they feel confident they have received the best treatment and
advice.
We understand that each patient has their own unique concerns and questions and our aim is to
ensure that the treatment and advice given fulfills their needs. We have a large cohort of national
and international experts in Digestive Diseases who are at the forefront of education. We are
involved in active research studies in all disciplines including upper and lower gastrointestinal as
well as liver disorders.
We are also fully committed to providing graduates and undergraduates with medical and nursing
training, offering them a wide and varied insight into the speciality. Continuity of care for Digestive
Diseases is maintained by working closely with Endoscopy to ensure a seamless pathway for
patients. This is also enhanced by staff rotation throughout both departments.
Services Provided
Digestive Diseases:
Colorectal, Gastroenterology, Hepatology, Pre Assessment clinic for Endoscopy, Faecal
Incontinence/ Sacral Nerve Stimulation,, Functional Bowel Disease services.
Urology:
General Urology Clinic, Flow Rate Measurement, Bladder Scanning, Trans Rectal Ultrasound and
biopsy of the prostrate gland (TRUS)
Achievement against Quality Improvement Objectives 2012/13
Quality Domain
Patient Safety
Our Quality Priority for 2012/13
Implement a robust process to
manage clinic cancellations.
Reduce patients appointments
rescheduling and improve
appointment wait times
Outcome
A standard operational policy was developed and
agreed with the clinicians to manage clinic
cancellations avoiding repeated rescheduling of
new and follow up patients by prioritising those
previously rescheduled. The benefit has now
been replicated across the Treatment Centre
which is now monitored on a monthly basis.
Information from this is shared with each unit and
if agreed tolerance levels are exceeded the
relevant action is taken
Status
Achieved
These patients are rebooked in a timely manner
appropriate to new or follow up scheduling
protocol. If no suitable appointment is available
this is escalated to manager and/or clinician for
further advice as required
Additional clinics are opened up in advance to
avoid reoccurrence
Patient
Experience
Reduction in wait times during
clinic so that patients do not
wait longer than 30 minutes
The waiting times audit recommendations
showed that the first appointments on lists were
frequently delayed. Appointment slots have now
been rescheduled to start later, avoiding delays.
67
Partially
Achieved
Digestive Diseases Quality Account 2012/13
from their appointment time
Appointment slots have been adjusted to
improve the patient flow
We now receive as many positive feedback
comments regarding waits as improvement
comments
A further review of new to follow up appointments
is being undertaken. The aim is to ensure
realistic appointment slots are provided for each
clinician
The receptionists and nursing team ensure that
patients are kept informed about delays as they
arise
Clinical
Effectiveness
Dedicated phone number for
patient queries regarding
test/scan/x-ray results
Patients will have their test
results with minimum delay.
Reassurance that a process in
place if concerned
Rather than develop a dedicated phone number
we improved the use of outcome forms to better
track patient results. Diagnostics investigations
are being recorded on this form and are
monitored to minimise delays
Superseded
Learning from Clinical Audits
The local clinical audits that the Clinical Unit have participated in during 2012-13 are as follows;
Clinical Outcomes x A detailed audit of individual FOLQLFLDQV¶ outpatient clinic sessions was undertaken to monitor
delays, patients seen per clinic, cancellations under 6 weeks, and the number of patients
that would recommend each clinician. This data was shared with each individual clinician
with areas of concern discussed at a clinical unit team to rectify issues raised.
x Recommendations - We plan to standardise the numbers of new to follow up patients seen
on each list in accordance with national guidelines, with a view to reduce waiting times.
Quality Review
After review of all our complaints, concerns and comments we have identified poor communication
around future appointments or procedures as a common theme. Although we have addressed
patient concerns during the year we are using this information to prioritise the improvement of
communication and information provided to patients. Along with the common theme identified
above there have been 2 isolated cases that have led to quality improvements relating to the
review of diagnostic results and the timely ordering of diagnostic investigations.
We recorded 124 incidents over the time period in question and one Stop the Line. We have seen
trend in appointment scheduling errors, and as such the unit has decided to make this a quality
priority for the forthcoming year with the 'right first time' initiative.
We have listened to what patients have told us with 4328 comments, 528 of which suggested how
we could make improvements to our services. We have seen recurring comments regarding
appointment waiting times and have used this information to prioritise this issue for 2013/14 by
increasing our pre-assessment staffing levels to reduce the wait for those patients who require preassessment.
During partnership events, team members suggested that both patients and staff would benefit
from a continuity of care between Digestive Diseases and Endoscopy. This has led to a quality
68
Digestive Diseases Quality Account 2012/13
priority to 2013/14 whereby staff engage with both departments to better understand the patient
pathway.
You Said:
We Did:
The waiting times audit recommendations showed that the first appointments on lists were
frequently delayed, these appointment slots have now been rescheduled to start later, avoiding
delays. Some clinicians were experiencing regular delays throughout lists. After a discussion their
booking times have been adjusted to improve the patient flow
That waiting
time for clinic
appointments
are too long
Can my wait for
the appointment
be more
comfortable
Lack of
information for
endoscopy
procedures
The nurses now inform the admin staff if any delays occur so this can be added to the patient
information screen in reception to ensure patients are kept informed at all times
A hot drinks machine is available to patients whilst waiting
We have installed a radio with music, magazine rack and book shelf which can be accessed whilst
waiting
We now run a pre assessment service for patients referred for endoscopy procedures following their
clinic appointments. Patients are given, on the day of their clinic appointment, full details of what
procedure entails in order to reduce anxiety and concerns prior to the procedure date
Quality Improvement Priorities for 2013/14
Quality
Domain
Best
Patient
Experience
Best
Clinical
Outcome
Our Quality Priorities for 2013/14
Success Measures for 2013/14
We are developing our Endoscopy preassessment service further to ensure the majority
of patients undergoing a procedure are given the
appropriate information and have their concerns
answered prior to their appointment date. We are
increasing our pre-assessment staffing levels to
incorporate an increase in telephone and face to
face appointments available
Clinicians reviewing diagnostic results
consistently in a timely manner
Reduced levels of anxiety on
admission to the endoscopy unit
as a result of information received
and concerns answered.
Reduced level of DNAs (Did Not
Attend) and cancellations to the
endoscopy lists
Ensure timely ordering of diagnostics
investigations
A monthly sample size audit of the
date each diagnostic tests are
ordered to ensure timeliness
IBD (Irritable Bowel Disease) patient pathway
developed to enable those requiring urgent
appointments are seen in a timely manner.
Patients have access to IBD nurse specialist for
advice. Nurse led clinic and telephone
appointments for follow up patients with
availability of annual follow ups in the community
and self management plans to allow access for
urgent appointments with clinicians as required
Most
Engaged
Staff
Healthcare Assistant (HCA) training to be
developed to become more specialty based
considering needs of staff requirements
We have worked with the
clinicians to develop an outcome
form to indicate which tests will be
carried out. These are recorded
on our patient administration
system, and monitored and
actioned daily
Rapid access appointment
available for flare-ups with
specialist clinicians
Long term follow up patients to
have easier access to advice and
appointments
Nurses, student nurses and HCAs
to work across Digestive Diseases
outpatients and Endoscopy to
provide a continuity through the
patient pathway and further
awareness of gastroenterology
diseases and treatments
69
Monitoring &
Reporting
Responsibilities
Clinical
Governance &
Risk
Management
Committee
(CGRM)
Clinical
Governance &
Risk
Management
Committee
(CGRM)
Clinical
Governance &
Risk
Management
Committee
(CGRM)
Statement from the Patient & Public
Engagement Committee
The Patient & Public Engagement Group has welcomed the opportunity to review, comment
and contribute to the Nottingham NHS Treatment Centre Quality Account for 2012/13.
All members of the Patient & Public Engagement Group have had the chance to be an
integral part of the Clinical Unit partnership sessions. This has provided us with the unique
opportunity to work jointly with clinicians and other healthcare staff to examine how their
services can work even better, offer a valuable patient perspective and facilitate
improvements. We have been openly welcomed to the partnership sessions and the
doctors, nurses and administrative staff have really taken the opportunity to learn from our
knowledge as patients and encouraged our challenges.
2012/13 has been both an exciting and dynamic year for the Patient & Public Engagement
Group and we have worked jointly with the Nottingham NHS Treatment Centre to assist in
the redesign of the rapid response patient feedback cards, review and update the Carers
Guide, make recommendations with regard to signage in the Treatment Centre, assist in the
development of the hourly rounding tool for the Day Case Clinical Unit, participate in the
µ6WRSWKH/LQH¶&DPSDLJQFRQVXOWRQWKHFRQWHQWRIWKH0\VWHU\6KRSSHUTXHVWLRQQDLUHDQG
participate in the Patient 1st Campaign.
The Patient & Public Engagement Group have had the opportunity to contribute to the
quality priorities that have been identified for 2013/14 and we are extremely pleased to see
that each priority has been written in DSDWLHQWIRFXVHGZD\WRHQVXUHWKDWZHDOOµVHH the
person in the patient¶
The Patient & Public Engagement Group are delighted that the Nottingham NHS Treatment
Centre has been awarded the contract to provide future services to NHS patients and we
feel that this will provide a great opportunity to progress the excellent programme of work
we have already embarked upon. We look forward to continuing the programme of joint
working and we are exciting about the development opportunities that will arise as the
Treatment Centre implement an integrated care model.
Mr Stephen Hyde, Chair
Patient & Public Engagement Group (June 2013)
Mr Tom Turner, Member
Patient & Public Engagement Group (June 2013)
73
Statement from NHS Nottingham City
Clinical Commissioning Group (CCG)
µ1+6 1RWWLQJKDP &LW\ &OLQLFDO &RPPLVVLRQLQJ *URXS &&* ZDV WKH OHDG FRPPLVVLRQHU IRU
Nottingham NHS Treatment Centre during 2012/13 on behalf of a number of commissioners. In this
role the CCG had responsibility for monitoring the quality and performance of services at Nottingham
NHS Treatment Centre throughout the year. The CCG is satisfied that the information contained
within this quality account is consistent with that supplied to us throughout the year.
There are a number of ways in which we review and monitor the performance and quality of the
services we commission. This includes visits to services, monthly quality and contract review
meetings and continuous dialogue as issues arise, for example patient safety incidents or patient
feedback. These mechanisms allow us to triangulate and review the accuracy of the information
being presented to formulate opinions about the quality of services provided to patients at both
organisation and service level.
Nottingham NHS Treatment Centre has worked constructively with commissioners and other partners
to respond to local commissioning intentions and develop integrated care pathways that improve the
health of the local community. These include participating in the national cancer peer review
programme to improve the quality of service provided to cancer patients and reducing waiting times
for appointments which have improved patient experience and safety. Quality goals and indicators
are jointly agreed in order to reduce health inequalities and improve the health of Nottingham and
Nottinghamshire residents.
Commissioners have seen a number of initiatives which have resulted in changes to culture, practice
and patient outcomes and these are reflected in this quality account. Nottingham NHS Treatment
Centre has also shown commitment to and achieved quality priorities which are important to
FRPPLVVLRQHUVIRUH[DPSOHWKHµVWRSWKHOLQH¶DQGWKHµ3DWLHQWst¶FDPSDLJQ
Nottingham NHS Treatment Centre continues to demonstrate a high level of commitment to
improving patient, carer and staff experiences of the organisation. A number of robust mechanisms
for receiving real time feedback have been established and it is clear that this feedback is treated
seriously and genuine efforts are made to improve services in the light of it. The Family and Friends
Test was introduced in 2012 ± 2013 and this will continue in 2013 ± 2014.
We are pleased to see that Nottingham NHS Treatment Centre continues to recognise the importance
of reporting patient safety incidents and are assured that when they occur (including those reportable
under the Department of Health criteria for Independent Sector Treatment Centres) robust
investigations are undertaken with a focus on learning and improving. The themes from incidents
reported during 2012 ± 2013 have been used to inform the quality improvement priorities for 2013 ±
2014.
Commissioners would like to note that they were pleased to see that not only has each service
contributed to setting priorities for the organisation but that in addition, each service has its own
distinct objectives to improve quality. This approach is to be commended as it makes clear what
needs to be achieved and enables progress to be reported upon openly in 2013 - 2014 at service
level
Work will continue with the Nottingham NHS Treatment Centre in 2013 ± 2014 to ensure the continual
TXDOLW\RIWKHVHUYLFHVSURYLGHGDQGWRPRQLWRUDFKLHYHPHQWRIWDUJHWVLQGLFDWRUVDQGSULRULWLHV¶
NHS Nottingham City Clinical Commissioning Group (CCG) (June 2013)
74
Statement from the Joint
Nottinghamshire Health Scrutiny
Committee
The Joint Health Scrutiny Committee welcomes the opportunity to comment on the
Nottingham NHS Treatment Centre Quality Account 2012/13.
No issues relating directly to the Nottingham Treatment Centre were identified for scrutiny
by the Joint Health Scrutiny Committee during 2012/13 and the Committee was not
consulted on or invited to engage in any work of the Treatment Centre during that period. A
reason for this was the tender process for the future provision of services at the Treatment
Centre which took place during 2012/13, and restricted the ability of Circle to engage and
share information that had been submitted as part of their bid.
However the Committee feels that the Quality Account is very clear in demonstrating what
the Nottingham Treatment Centre has done to achieve its priorities for 2012/13. It is also
positive to see clear identification in the Quality Account of issues that have arisen during
the year (through staff and patient feedback), the lessons that have been learnt and where
things have changed to the benefit of patients.
Councillor Ginny Klein, Chair
Joint Nottinghamshire Health Scrutiny Committee (June 2013)
75
Jargon Buster
Apps/
Applications
Credo
A specialised piece of software (which can run on the internet, on your computer,
or on your mobile phone or other electronic device) and is designed to undertake
a specific task. For example to monitor waiting times in clinic
A set of fundamental beliefs or a guiding principle. For Circle, a credo is similar to
a mission statement that guides the way in which we deliver healthcare. The
Circle principles are:
x We are above all the agents of our patients. We aim to exceed their
expectations every time so that we earn their trust and loyalty. We strive to
continuously improve the quality and the value of the care we give our
patients.
x We empower our people to do their best. Our people are our greatest
asset. We should select them attentively and invest in them
passionately. As everyone matters, everyone who contributes should be
a Partner in all that we do. In return, we expect them to give their
patients all that they can.
x We are unrelenting in the pursuit of excellence. We embrace innovation
and learn from our mistakes. We measure everything we do and we
share the data with all to judge. Pursuing our ambition to be the best
healthcare provider is a never-ending process. 'Good enough' never is.
Dashboards
An easy read, often single page, real-time user interface, showing a graphical
presentation of the current status (snapshot) and historical trends of an
RUJDQLVDWLRQ¶VNH\SHUIRUPDQFHLQGLFDWRUV.3,VWRHQDEOHLQVtantaneous and
informed decisions to be made at a glance
Innovator
An individual with the ability to make change
IRMER
Ionising Radiation (Medical Exposure) Regulations
Joint
The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) operates within
Advisory
the Clinical Standards Department of the Royal College of Physicians. JAG has a
Group (JAG) wide remit and its cores objectives include: to agree and set acceptable standards
for competence in endoscopic procedures and, to quality assure endoscopic units,
training and services
NCAPOP
National Clinical Audit and Patient Outcomes Programme
NICE
National Institute of Clinical Excellence
NPS
Net Promoter Score
Partnership
Educational, discussion and solution focused sessions held within clinical units
Sessions
and open to all staff involved in the patient pathway. The purpose of the sessions
is to improve competence and educate staff, enable discussions of any issues that
have arisen and provide the opportunity to develop realistic and effective solutions
Peer review
A process of self-regulation by a profession or a process of evaluation involving
qualified individuals within the relevant field. Peer review methods are employed
to maintain standards, improve performance and provide credibility
Preceptorship A period (of preceptorship) to guide and support all newly qualified practitioners to
make the transition from student to develop their practice further
PROMs
Patient Reported Outcome Measures
Rapid cycle
A quality improvement technique that allows staff to identify areas for
feedback
improvement in existing patient pathways and allows prompt, effective solutions to
be implemented which improve the patient flow and enhance the quality of care
that patients receive
SWARM
A term used to refer to a gathering of the relevant staff in order to discuss propose
solutions and agree actions following an issue which has arisen. This is part of
our Circle operating system methodology
WHO
World Health Organisation
76
We welcome your feedback:
Nottingham NHS Treatment Centre
4XHHQ¶V0HGLFDO&HQWUH&DPSXV
Lister Road
Nottingham
NG7 2FT
Email: PALS.Nottingham@circlepartnership.co.uk
Website: www.circlepartnership.co.uk