ROYAL CORNWALL HOSPITALS NHS TRUST
QUALITY ACCOUNTS 2012/2013
RCHT 2012/13 Quality Account: Final
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CONTENTS PAGE
Contents
Page
Part 1: Chief Executive’s statement
4
Part 2: Priorities for Improvement
6
A. Review of 2012/13 priorities for improvement
Patient Safety
Patient flow including single point of access and
ambulance turnaround times
Implementation of the Safety Thermometer: reducing
incidents of harm
Clinical Effectiveness
Designation of RCHT as a Trauma Unit in the
Peninsula Trauma Network
Improved pathway for Glaucoma patients
Patient Experience
Quality of discharge including information provision
B. Priorities for improvement 2013/14
Patient Safety
Safety Thermometer, reducing harms
Clinical Effectiveness
Preventing admissions from high risk patients
Staff health and wellbeing
Patient Experience
Improving the discharge experience for patients and
reducing unnecessary discharge delays
CARE campaign
C. Board statements of assurance
Review of our performance 2012/13
National priorities and existing commitments
Incident reporting and Never Events
Participation in Clinical Audits
Research and Development
Commissioning for Quality and Innovation (CQUIN)
How the NHS regulator, the Care Quality
Commission, views the quality of our services
Data Quality
Information Governance Toolkit attainment levels
Clinical coding error rate
National Quality Indicators
6
6
6
Part 3: Review of the Trust’s quality performance
Patient Safety
Obstetrics and Gynaecology service review
Lower segment caesarean section surgical site
RCHT 2012/13 Quality Account: Final
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infection surveillance (SSI)
Clinical Effectiveness
Lung cancer
Junior doctors in training
Cornwall Vascular Unit
Audiology
Laparoscopic colorectal surgery
Bariatric and Metabolic surgery
Patient Experience
National A&E (ED) Survey
National In-Patient Survey
Early supported discharge for stroke
Young Peoples takeover event in Sexual Health
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Involvement and Stakeholder Engagement
Statements from Healthwatch, Health Overview and Scrutiny
Committees and Clinical Commissioning Groups
Kernow Clinical Commissioning Group
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Cornwall Health and Adults Overview and Scrutiny
Committee
Healthwatch Cornwall
Isles of Scilly Health Overview and Scrutiny
Committee
Healthwatch Isles of Scilly
Trust response to comments from third parties
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Statement of Directors' Responsibilities in Respect of the Quality
Account
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Independent Auditors’ Report
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RCHT 2012/13 Quality Account: Final
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Royal Cornwall Hospitals NHS Trust
Quality Accounts 2012/13
PART 1 Chief Executive’s statement on behalf of the Trust Board
Welcome to this year’s Royal Cornwall Hospitals NHS Trust Quality Accounts.
The report builds on last year’s quality accounts identifying our performance in
2012/13 and our improvement plans for 2013/14.
‘Our plans 2012 – 2017’ published in July 2012 continues our commitment to
the delivery of better, safer, good value care outlined in our previous plans
‘2010-2014’.
The Trust has consistently maintained ‘performing’ status since May 2009
which means, together with our unconditional CQC registration, our overall
performance is viewed positively. The Trust continues to work towards being
authorised as a Foundation Trust and continues to be the preferred provider of
acute services for the people of Cornwall and the Isles of Scilly.
The CQC visited the Trust in November 2012 as part of their scheduled
inspection programme. I am pleased to say that the Trust was found to be
compliant with all the outcomes assessed, at all the locations visited.
I, together with the rest of the Trust Board, apologise unreservedly for the pain
and distress caused to some of our patients by the care and treatment they
received from one of our former gynaecology consultants. Throughout 2013/14
we will continue to implement the recommendations of the five review reports
published in February this year.
The information within this year’s quality accounts provides a good insight into
the progress made against our objectives. Particular highlights are:
• No cases of MRSA bacteraemia for the second successive year
• National recognition for our Lung Cancer Team in the Improving Lung
Cancer Outcomes Project
• GMC commendation for 3 areas of best practice in junior doctors
training; more than any other Local Education Provider in the Peninsula
• The achievement of CNST level 3 by our Obstetric service
In consultation with our staff, service users and stakeholders, the Trust has
identified a number of areas for improvement for the forthcoming year:
• We will continue to reduce the levels of avoidable harm using the NHS
Safety Thermometer
• We will work with our partners to identify and prevent the re-admission
of high risk patients to our hospitals
• Our staff are essential in delivering high quality patient care; through the
“Our people” workforce strategy we will support and develop our staff to
their full potential
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•
•
We are committed to improving the quality of hospital discharge for our
patients by improving the information we provide and reducing
unnecessary delays in discharge
The CARE campaign was launched in May 2012 focussing on the basic
elements of nursing care. Success is measured through our patient
experience survey. We will work to ensure our patients have a positive
experience all of the time.
I am pleased to publish our fourth quality accounts and to confirm my personal
commitment to providing high quality health care for the people of Cornwall
and the Isles of Scilly.
To the best of my knowledge the information in these quality accounts is
accurate.
Lezli Boswell
Chief Executive
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PART 2 PRIORITIES FOR IMPROVEMENT
A. Review of 2012/13 priorities for improvement
Patient Safety
1. Patient flow including single point of access and ambulance
turnaround times
As described in last year’s accounts, the Trust has undertaken a number of
initiatives to improve the flow of patients through our hospitals. These include:
The Ambulatory Care Unit opened in October. This is a GP led assessment
area that aims to reduce hospital admissions.
We have continued to develop the Integrated Hospital Discharge Team.
Development of carepathways for elderly patients are now included in the
Trust’s 5 year plan for 2018.
The Clinical Site Development Plan for surgery is progressing according to
plan:
• Vascular Surgery is now on Wheal Coates ward in Trelawny Wing.
• The Ophthalmology out-patient department has moved to the Tower
Block.
• Theatre Direct has been temporarily relocated to allow for redesign of
the facility.
• Laminar flow is being installed in theatres 10 and 11 to provide a new
elective orthopaedic theatre suite followed by integrated laparoscopic
theatres being installed in theatres 8 & 9; estimated to be completed by
September 2013.
• All of the above are required prior to the Surgical Receiving Unit being
relocated in Trelawny wing alongside the new GI (Gastro-intestinal)
ward due for completion in December 2013.
The Urgent Care Centre at West Cornwall Hospital opened in July and has
been received positively by both the GPs who work there and our patients.
An accelerated pathway is in place at St Michaels Hospital and working well so
that patients requiring hip or knee replacement surgery have a one stop
service and leave the hospital with their date for surgery. We are the only
orthopaedic provider in Cornwall to provide this service. Feedback from
patients is very good.
Work is on-going to improve the flow of patients to West Cornwall Hospital
(WCH) with the development of ‘live’ waiting lists for WCH.
Single Point of Access is due to be delivered in summer 2014. Phase 1 of the
Emergency Department (ED) build is nearing completion and the minor injuries
area has been relocated into the old fracture clinic and now has its own
RCHT 2012/13 Quality Account: Final
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entrance and reception area. Phase 2 has commenced with work currently
underway to refurbish Gerrans and increase trolley capacity for majors.
The Medicine division has developed a bed strategy for the next three years
which includes additional care of the elderly beds and a dedicated frailty unit.
The 30 minute ambulance turnaround target remains a local contractual
requirement; the Trusts performance over the year is reflected in the chart
below.
Ambulance Delays - Numbers waiting over 30 minutes
350
313
300
250
250
107
82
67
64
105
137
202
171
46
50
73
100
108
163
150
151
127
97
78
83
75
70
30
81
28
102
113
114
200
0
Actual
Ambulance handover delays continue to be similar to the regional average.
This has occurred despite additional measures put in place for winter including
a discharge lounge, additional ED staffing, medical MDTs, an Ambulatory
Care facility and a 7 day therapy pilot.
A number of new areas for improvement have been identified:
• ED environment improvement. Phase 1 of the ED re-development plan
is nearing completion and the re-provision of minors and paediatrics is
planned to be completed by the end of 2013. This will align the
configuration of ED to better meet the needs of paediatrics, minors and
majors.
• Reconfiguration of the bed base within medicine.
• Reduce length of stay, initially focusing on patient stays of over 10 days.
• Improved management of frail elderly patients.
• Provision of ambulatory care facilities in Medicine.
• Streamline surgical admissions.
Joint working arrangements between RCHT and SWAST have remained in
place, with an action plan including escalation processes and daily validation in
place, and SWAST being very supportive of the challenges being faced by
RCHT during the winter months. The Trust is expecting to continue this close
joint working into 2013/14.
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2. Implementation of the Safety Thermometer: reducing incidents of harm
In April 2012, the NHS Safety Thermometer Tool was successfully
implemented in all inpatient areas.
The Safety Thermometer Tool assesses all inpatients on a specific pre-set
date on the basis of how well patients are protected from “4 harms”:
• Pressure Ulcers.
• Falls.
• Catheter Associated Urinary Tract Infection (CAUTI).
• Venous Thromboembolism (VTE).
The data collected between April 2012 and March 2013 gave the Trust an
overall monthly “harm free care” rating of between 89% and 94%.
RCHT Safety Thermometer - RESULTS REPORT
Harm Summary
new Harm
100
old harm
% Harm Free Care
% New Harm Free
98%
97%
% Harm Free
All Harms
New Harms
100%
Apr-12
89.38%
93.84%
95%
May-12
90.60%
94.65%
90%
Jun-12
91.61%
96.06%
85%
Jul-12
91.76%
95.97%
60
80%
Aug-12
92.40%
95.95%
50
75%
Sep-12
92.92%
97.53%
70%
Oct-12
93.60%
96.71%
Nov-12
93.45%
97.17%
Dec-12
94.15%
96.04%
94%
95%
96%
96%
96%
97%
96%
97%
96%
96%
90
80
70
89%
26
91%
92%
92%
92%
93%
94%
93%
94%
93%
92%
93%
25
40
26
25
21
30
20
28
36
25
25
18
22
18
65%
11
60%
33
23
10
24
24
15
19
16
23
24
22
25
Jan-13
92.71%
96.59%
Feb-13
92.20%
96.18%
Mar-13
93.11%
95.99%
55%
50%
0
SUMMARY
FALLS
VTE
PRESSURE ULCER
UTI
The term “harmfree” care directly associated with the Safety Thermometer is
now recognised as a key goal in quality improvement.
Reducing the number of pressure ulcers that develop in our hospitals has been
given high priority by the nursing leadership. Actions identified last year to
improve practice and process to prevent pressure ulcers are proving
successful. Overall the Safety Thermometer evidence from April 2012 to
March 2013 shows a reduction in new pressure ulcers from 2.89% to 1.76%
which indicates that the action plan is succeeding in its intended goal, though
further progress needs to be made. Changes in place include improvements in
compliance with the SKIN (Surface inspection, Keep moving, Incontinence,
and Nutrition) bundle and rolling out the lower limb pathway to all vulnerable
patients at risk of pressure ulcers.
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Implementation of the Royal College of Physicians “fallsafe” care bundle was
rolled out to the top 16 high risk ward areas in January 2013. The bundle
includes the further embedding of CARE rounds (intentional rounding) across
all wards and departments, a review of Multi-Disciplinary Team (MDT) practice
to ensure that there is timely review of multifactorial risk factors (particularly
after a fall) and an open review at the falls group of falls incidents where
patients have come to harm. Intentional rounding is a process where nurses
and support staff carry out regular checks with individual patients at set times.
At the end of the check the patient is asked “Is there anything else I can do for
you?”
While there has been little improvement in our overall monthly falls rate across
the Trust, we have achieved an assurance that all falls are now reported on
Datix (the Trust’s incident reporting system) by doing a cross comparison of
safety cross data, Datix and Safety Thermometer data. All health care
organisations in the south west undertaking falls improvement work under the
Quality and Patient Safety Improvement Programme (QPSIP) have reported
the same difficulty with improving falls rates. All actions identified following a
review of complaints relating to falls have been completed.
Clinical Effectiveness
1. Designation of RCHT as a Trauma Unit in the Peninsula Trauma
Network
Following the designation of the Trust as a Trauma Unit in the Peninsula
Trauma Network the unit has worked hard to meet the requirements set by the
network.
Compliance with dataset submissions to the Trauma, Audit and Research
Network (TARN) have continued to improve, however our comparison figures
to HES (Hospital Episode Statistics) data suggest that we have only identified
65% of entries for 2012. We have looked into this and believe that the HES
data is misrepresenting the TARN-eligible population. We have discussed this
with TARN and they have looked in detail at our data submission. Of the 1
month dataset submitted to TARN using their identification algorithms, we had
submitted over 80% and also identified additional eligible patients not picked
up by the TARN algorithm, bringing us over 90% of expected. We will submit
these findings to the Network and request a review of the base figures or
acceptance that our dataset is robust.
Patient satisfaction and feedback surveys have been developed and ratified by
the Major Trauma Review Group. They are to be sent out to patients being
entered into the TARN database. Unfortunately we haven’t been able to
identify a patient representative to sit on our Major Trauma Review Group.
The rehabilitation coordinator for the Peninsula Trauma Network has been
appointed. The Trust is working with the coordinator to develop the directory of
services.
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Senior nursing staff from the Emergency Department (ED) have attended all
three TNCC (Trauma Nursing Care Course) courses run by the Peninsula
Trauma Network. Two sessions of the Trauma Intermediate Life Support
course have been successfully completed by 21 ED staff nurses and 2
members of the Search and Rescue medical team. This course ensures all
participants are trained in relevant trauma knowledge and skills. A further
course is planned for late July 2013. The Trauma Team Training course is
being run centrally in Derriford five times this year and we expect to send two
teams to this.
An audit of Trauma Team Attendance is nearing completion.
The Primary Survey reporting of trauma scans is in place. Use of this tool has
not been universal and therefore feedback has been provided to radiology staff
reporting on the scans as well as to the radiology departmental audit meeting.
The need for early request for Trauma CT has been highlighted to all trauma
team leaders (ED consultants). Feedback is being provided to staff involved
following trauma calls.
The collection of Key Performance Indicators (KPIs) is still being decided at a
Network level. Discussions between the Trust and the Peninsula Trauma
Network as to what is expected and how this is to be achieved are ongoing.
The Major Trauma Review Group continues to oversee multi-divisional
pathways of care for major trauma patients as per its Terms of Reference.
2. Improved pathway for Glaucoma patients
In 2012 the Glaucoma Assurance Group designed and implemented a new
administrative process which identifies patients with Glaucoma on the Patient
Administration System. This has enabled RCHT to identify patients with
Glaucoma and produce a monthly management report showing the demand,
for example Glaucoma patients on the pending list and whether they were
overdue. The Service Lead then matched this with capacity; a shortfall was
identified.
The new Glaucoma Monthly Management Report also shows DNA (Did not
Attend) rate for Glaucoma patients. For January 2013 the DNA rate for patients
with Glaucoma was 5.26%. This is better than the national upper quartile for
Ophthalmology.
The Service Lead is currently implementing a recovery plan to address the
shortfall identified. Additional staff are being recruited and a recovery plan
developed to provide additional acute hospital based capacity which includes:
• Additional consultant clinics
• Additional photography clinics
February 2013 saw the launch of the Primary Care Monitoring Ocular
Hypertension and Suspected Glaucoma enhanced service. This will receive
approximately 1500 referrals from RCHT to the community optometrists.
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Patient Experience
1. Quality of discharge including information provision
Across the medical wards daily multidisciplinary meetings occur in front of their
electronic interactive bed status boards. The team will review all patient
trajectories to make plans and prioritise work activities for the day. All areas
have now adopted the new simplified template and new icons. Feedback from
the teams continues to be positive in respect to better team decision making
and prioritising, improved team communications and improving information
about discharge plans to patients.
The ‘When will I go Home?’ discharge booklet was re-launched over the spring
of 2012. Monitoring of the booklet being issued to each inpatient is now
reported quarterly for each ward in a new set of discharge related key
performance indicators. We are currently reporting about half of patients have
documented evidence that they have been given a copy – this new monitoring
arrangement reported into ward level quality performance reports will now start
to drive up the rate of booklet availability for inpatients.
Progress on the development of bedside information was initially delayed due
to problems securing a publisher. The new concept of launching a bedside
‘newspaper’ has progressed through engagement with our new Patient
Ambassadors. The Trust’s ‘Readers Panel’ is reviewing content, specifically
the content relating to discharge process and planning. The launch of this new
publication is anticipated for the summer of 2013.
B. Priorities for improvement 2013/14
Process for agreeing our priorities for improvement
A list of priority areas for improvement was circulated to the Trusts
stakeholders for comment in February based on the following evidence:
• Engagement during 2012/13 with our patients and the public in the
community we serve.
• FT Quality Assessment.
• The National Outcomes Framework.
• NHS Information Centre.
• Commissioning for Quality and Innovation (CQUIN) programme.
• National and local patient experience surveys.
• Royal Cornwall Hospitals NHS Trust Strategic Plans 2012-17.
• Intelligence from our internal mechanisms for monitoring the quality of
our services.
Feedback received was used to finalise the priority areas and also to inform
the performance review section of these accounts.
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Patient Safety
1. Safety Thermometer: reducing harms
The safety of our patients is of paramount importance to the Trust. We have
therefore decided to keep the Safety Thermometer as one of our key quality
improvement measures for 2013/14.
The aim of the Safety Thermometer is to achieve improvements based on a
‘harm free’ care rating which is drawn from a monthly point of care audit of all
inpatients on a single specified day per month as previously described. The
data collection method promotes the prevention of harm and patient safety by
counting the cost from the patient’s perspective and experience.
The primary aim is to prevent harm in our care and to work effectively with our
partners in the community so that harm is reduced across the healthcare
community as a whole.
The intended outcome is to prioritise “harmfree” care among our frontline
teams, then proactively put changes in place which prevent harm rather than
just counting the consequences.
In collaboration with our community partners a target for the prevention of
pressure ulcers (PU) has been agreed based on the 2012/13 Safety
Thermometer pressure ulcer baseline data.
Apr
12
May
12
Jun
12
Jul
12
Aug
12
Sep
12
Oct
12
Nov
12
Dec
12
Jan
13
Feb
13
Mar
13
Percentage of patients with
either an old or new pressure
ulcer
6.79
5.83
6.18
4.87
4.82
5.1
4.84
4.63
3.61
3.72
4.62
4.49
Percentage of patients with a
new RCHT acquired pressure
ulcer
2.89
1.94
1.77
0.84
1.2
1.53
1.9
1.72
1.89
0.78
1.43
1.76
No. of patients (RCHT)
589
617
566
595
581
588
578
583
581
645
628
624
While the target has been agreed for this year to focus on pressure ulcers, the
Trust will make full use of the Safety Thermometer initiative to reduce all four of
the avoidable harms. The Safety Thermometer working group will review
activity with the relevant harm groups to assist plans and prevent harm across
all the harm domains.
Identified areas for improvement:
• Ensure full compliance with the on-going Safety Thermometer data
collection for all inpatients.
• Reduce the incidence of hospital acquired pressure ulcers.
RCHT 2012/13 Quality Account: Final
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•
•
•
•
•
Achieve a reduction in falls using the fallsafe care bundle and coordinating falls reduction with other groups within the southwest Quality
and Patient Safety Improvement Programme.
Achieve compliance with trustwide implementation of CARE rounding
and SKIN bundle to prevent falls and pressure ulcers.
Implementation of the single system catheter for the prevention of
catheter associated urinary tract infection.
Reduce the incidence of patient falls resulting in harm by 50% from
2009 to 2013.
Reduce the incidence of combined harm over the four harms identified
above.
A Safety Thermometer working group of key stakeholders will remain in place
to ensure that there is compliance with the monthly data collection from April
2013 and that the target for harm reduction is achieved by reviewing planned
activity from the harm groups.
Data from the Safety Thermometer tool will be amalgamated to achieve a trust
wide “harm rating” for inpatients and uploaded to the NHS Information Centre
(NHSIC). This data is available in the public domain and is made available for
comparison with other trusts. Results are distributed to all ward areas within
one week of data collection and are a key safety indicator on the Performance
Assurance Framework (PAF). Performance and learning outcomes are
formally reported to the Governance Committee and the Divisional Quality and
Learning Group.
Clinical Effectiveness
1. Preventing re-admissions from high risk patients
The Trust continues to monitor the rates of patients requiring re-admissions
following patients being discharged from the Trust. A detailed audit was
conducted of re-admissions and the vast majority were found to be
unavoidable or unrelated to the original admission.
The rate of re-admissions is monitored on a monthly basis by each of the
clinical divisions and is a vital component of the PAF which is used to monitor
clinical performance and ensure we detect any changes in performance.
For 2013/14 the Trust plans on-going work with the wider heath community
and social services to devise new strategies to ensure that patients are not
readmitted to hospital unnecessarily. Examples include ensuring that patients
who are discharged have full electronic discharge plans sent to their GP at the
time of discharge to ensure there is a clear plan for treatment and follow up of
chronic conditions such as diabetes, chronic lung disease and heart failure. In
addition steps will be put in place that relevant specialist follow up is arranged
with patients after admission with certain conditions, such as diabetic
ketoacidosis, to ensure patients have received all the appropriate education to
avoid further admissions.
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2. Staff health and wellbeing
The Health and Wellbeing strategy was initiated following the Boorman review
of NHS health and wellbeing. Dr Boorman gathered a wealth of evidence of
the state of health and wellbeing in the NHS, its impact on care and cases of
best practice. Health and wellbeing is increasingly being acknowledged as a
vital element in supporting and developing the workforce. It is now a key part of
the "Our People" Human Resources strategy.
Through "Our People" The Health and Wellbeing strategy aims to:
1. Create a safe and healthy working environment
2. Improve physical and emotional well being
3. Encourage and support employees to develop and maintain a healthy
lifestyle
4. Support people with manageable health problems or disabilities to
maintain access to or regain work
5. Improve staff satisfaction, recruitment and retention
To achieve these aims we will introduce wellbeing initiatives, employee support
mechanisms and joint working with staff, their representatives and local
partners to identify and address areas for improvement. Through the “Listening
into Action" programme and redesigning services in line with the aims in "Our
People" we will work with employees to ensure our organisation identifies and
minimises those issues which may impact negatively on staff health.
Principal aims in addition to those outlined above are:
•
•
•
To proactively work with staff to prevent ill health occurring.
When staff are unwell, to help them access timely and appropriate
services that will facilitate their recovery.
To work in partnership with staff to provide a fair and consistent policy,
treating staff with dignity and respect.
Key indicators
The Launch of the Listening into Action (LIA) programme in 2012 resulted in
Health and Wellbeing becoming one of 10 key LIA projects. The Health and
Wellbeing workstream is personally chaired by the Chief Executive and
initiated three areas of activity:
RCHT 2012/13 Quality Account: Final
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•
•
•
The agreement to investigate options for an Employee Assistance
programme
To undertake work with staff on values and behaviours
A new sickness absence policy developed in partnership with staff side
In addition to this work the Trust has for the second year participated in the
evaluation for the “Cornwall Healthy Workplaces Award” and will be awarded
“gold” status.
The Trust is also redesigning Occupational Health services to focus on
prevention and Health and wellbeing support for staff, introducing an
“Employee Treatment Support Programme” to help staff who are awaiting
treatment.
Work has been completed to understand the reasons for absence in the Trust.
As a result of this we are working with the European Centre for Environment
and Human Health to devise an action plan to tackle stress in the workplace.
We are also working with NHS Employers using dedicated support to develop
an action plan.
Each division has a dedicated Human Resources professional supporting
managers in understanding the local patterns in key areas and responding to
staff needs. We also produce workforce information identifying current rates of
absence and trend data. This data is published monthly to divisional
management teams and discussed weekly at the Operational Management
Group. Each division is performance managed though the Trust performance
management process.
Following the launch of the “Our People” strategy for Human Resources work
is due to commence to develop a manager ‘self-service’ IT solution, enabling
the reporting of absence to payroll and absence data to be available to
managers in real time.
Patient Experience
1. Improving the discharge experience for patients and reducing
unnecessary discharge delays
This area of collaborative care planning involves the person in hospital, often
their carer and family members and a wide multiprofessional team. The
process forms part of the vast majority of our patient journeys. From the
‘simple’ to the most ‘complex’ discharges, they all require the skilful coordination of tasks, individuals and teams, as well as expectations to be
successful. Increasingly we have seen a rise in the number of people in
hospital delayed for various reasons which is not good for the person who no
longer needs an acute hospital bed. In many ways discharge is an art rather
than an exact science and for this reason such a simple sounding and routine
process can sometimes go wrong. We are committed to making sure we get it
right every time, and when we don’t, to learn from the issues identified to
improve our services.
RCHT 2012/13 Quality Account: Final
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Identified areas for improvement
•
•
•
•
•
Improve compliance with our best practice policy on discharge.
Increase multiprofessional educational opportunities in aspects of the
discharge process.
Monitor the impact of educational initiatives.
Establish a mechanism to learn from discharges that don’t go right.
Minimise the bureaucratic burden of the current discharge process.
Key initiatives to deliver in 2013/14
•
•
•
•
Introduce service improvement methods to improve compliance with
delivery of the discharge policy.
Scope and introduce creative multiprofessional discharge training
opportunities in areas of discharge practice.
Develop measurement tools to monitor the impact of education on
discharge.
Develop and implement electronic information sharing systems to
communicate discharge information between care partners.
2. CARE campaign
The Trust publically launched its commitment to the CARE campaign in May
2012 in collaboration with the Patients Association and the Nursing Standard.
The campaign focuses on the four aspects of care that the Patients
Associations’ national help-line received most concerns about:
C - Communicating with compassion.
A – Assisting with toileting needs, maintaining dignity.
R – Relieving pain effectively.
E – Ensuring adequate nutrition.
These elements of care are central to the Trust’s ambition to focus relentlessly
on the quality of care we give to remain the preferred provider of acute and
specialist healthcare to the people of Cornwall and the Isles of Scilly. CARE is
the central element of the Trust’s Nursing and Midwifery Strategy.
Since the campaign’s launch, through the Trust’s patient experience survey,
we have measured these four aspects of care through eight key questions. The
survey results report high patient satisfaction with, on average, 99% of patients
responding positively to the questions (combined ‘yes always’ and ‘yes
sometimes’ response options). The most improved area of CARE has been in
‘Ensuring adequate nutrition’, improving from 94% to 99%.
In 2013/14 the Trust aims to address the variability in CARE patient’s report we
give, with a target to reduce the ‘yes, sometimes’ responses and increase the
‘yes, always’ responses to the eight questions in our survey. In the December
2012 survey results the average variability (‘yes, sometimes’ responses) was
11%.
RCHT 2012/13 Quality Account: Final
16
Key indicators:
Increase the ‘Yes, always’ response rate to the CARE questions (halving the
‘Yes sometimes rate):
C - Communicating with compassion from 90% to 95%.
A – Assisting with toileting needs, maintaining dignity from 92% to 96%.
R – Relieving pain effectively from 88% to 94%.
E – Ensuring adequate nutrition from 88% to 94%.
Progress will be monitored through the continuation of the eight questions
within the revised friends and family test patient survey.
C. Board statements of assurance
These accounts have been developed taking into regard any guidance issued
by the Secretary of State which relates to Chapter 2 of the 2009 Health Act.
During 2012/13 the Royal Cornwall Hospitals NHS Trust provided and/ or subcontracted 80 NHS services.
The Royal Cornwall Hospitals NHS Trust has reviewed all the data available to
them on the quality of care in 80 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 Royal Cornwall Hospitals NHS Trust for 2012/13.
Review of our performance 2012/13
National Priorities and Existing Commitments
As a non-Foundation NHS Trust, the Trust is assessed against the Department
of Health’s Performance Framework as either ‘performing’, ‘performance under
review’ or ‘underperforming’. Performance against the Framework in 2012/13 is
summarised overleaf. The Trust has sustained ‘performing’ status consistently
since Q2 2009/10.
RCHT 2012/13 Quality Account: Final
17
DH Performance Framework 2012-13
Thresholds
Higher Lower Timings Weighting Apr-12
Indicator
May-12
Jun-12
Jul-12
Achieved
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Projected
Feb-13
Mar-13
95%
94%
monthly
1.0
0
0
0
3
3
3
3
3
0
2
0
0
MRSA bacteraemias
1 in
2012/13
<1s d
ytd
1.0
3
3
3
3
3
3
3
3
3
3
3
3
Clostridium Difficile Post 72 hour infections
41 i n
2012/13
<1s d
ytd
1.0
3
3
3
3
3
3
3
3
3
3
3
3
90%
85%
monthly
1.0
3
3
3
3
3
3
3
3
3
3
3
3
95%
90%
monthly
1.0
3
3
3
3
3
3
3
3
3
3
3
3
92%
87%
monthly
1.0
3
3
3
3
3
3
3
3
3
3
3
3
0
>20
monthly
1.0
3
3
2
2
2
2
2
2
2
3
2
2
99%
95%
monthly
1.0
3
3
3
3
3
3
3
2
3
3
3
3
5% lower
tha n
monthly
upper
3.0
8.5
9
8.5
9
9
9
8.5
7.5
8.5
7.5
8.5
8.5
Maximum waiting time of 4 hours in ED
RTT admitted pathways (overall
performance)
RTT non-admitted pathways (overall
performance)
RTT incomplete pathways (overall
performance)
RTT delivery in all specialties (including
admitted, non-admitted and incomplete)
Diagnostic tests (% within 6 weeks)
Va rious
Cancer indicators
Delayed transfers of care YTD
<3.5%
5%
monthly
1.0
2
3
2
3
3
3
2
2
3
0
2
3
Mixed sex accommodation
0.0%
0.5%
monthly
1.0
3
3
3
2
3
2
3
3
3
3
3
3
VTE risk assessment
90%
80%
monthly
1.0
3
3
3
3
3
3
3
3
3
3
3
3
14.0
37.5
2.68
39
2.79
36.5
2.61
40
2.86
41
2.93
40
2.86
39.5
2.82
37.5
2.68
37.5
2.68
36.5
2.61
36.5
2.61
37.5
2.68
Total
Score
Status on Service Performance
Performing Performing Performing Performing Performing Performing Performing Performing Performing Performing Performing Performing
Col our code
0.0
0.0
1.5
0
RCHT 2012/13 Quality Account: Final
no or low risk
achievement predicted but higher risk
points dropped on indicator - lower threshold achieved
both thresholds failed for indicator
18
Emergency Department Access
The main performance difficulty encountered by the Trust in 2012/13 has been
the consistent achievement of the ED 4 hour target which was failed in Q1 and
in Q4. A number of actions have been put in place including:
• Establishment of an Executive Whole System Patient Flow and Delayed
Discharges Improvement Group, with an action plan to improve patient
flow across the system.
• New building works now underway within the department to expand the
currently limited space available which impacts on the patient
experience.
• Piloting ambulatory care in MAU and the establishment of an Urgent
Care Centre at West Cornwall Hospital.
• Ongoing work with Peninsula Community Health and Adult Social Care
to make sure where clinically appropriate patients are transferred to
community hospitals or return home with packages of care.
• Internal actions within the Emergency Department, such as improved
breach analysis and increased staffing at peak times.
RTT/ Waiting Times
The progress which was noted in last year’s quality accounts has largely been
sustained and the national admitted, non-admitted and incomplete pathway
standards have been sustained all year.
C Difficile and MRSA
The Trust has met both of these standards for 2012/13. During the year there
were 26 instances of C Difficile, which means that the Trust is doing slightly
better than the 2013/14 England ambition levels of 13 cases per 100,000 bed
days. There have been no cases of MRSA all year.
Venous Thromboembolism (VTE) Risk Assessments
The Trust assessed 97.02% of patients on admission for the risk of VTE during
2012/13. The national target of 95% was exceeded every month.
Delayed Transfers of Care
The level of delayed transfers of care increased in 2012/13 for the second year
running. The Trust continues to work with key partners including Peninsula
Community Health and Adult Social Care through the Whole Systems
Resilience Network to ensure that patients are discharged in an appropriate
and timely fashion.
Indicators for Cancer
There are several indicators to which the NHS must work for cancer referral
and treatment. The data in the DH Performance Framework table includes
standards which relate to the percentage of patients with a:
RCHT 2012/13 Quality Account: Final
19
•
•
•
Maximum waiting time of two weeks from referral to the date first seen
for all urgent suspected cancer referrals (target 93%).
One month (31 days) wait from diagnosis to treatment:
o For subsequent treatments for all cancers (surgery 94%, drug
98%, radiotherapy 94%).
o Of all cancers (96%).
Maximum two month (62 days) wait for first treatment from either:
o Urgent GP referral (85%).
o Consultant screening referral (90%).
Each of these targets was achieved on a quarterly and full year basis.
The Trust is well placed to maintain ‘performing’ status into 2013/14.
During 2012/13, the Trust has also assessed itself against Monitor’s
Compliance Framework for aspirant Foundation Trusts. It has achieved the
following results with the only penalty points incurred relating to ED
performance in Q1 and Q4:
Q1
RCHT Monitor
Compliance Framework
Ambergreen
Q2
Q3
Green
Q4
Green
Ambergreen
Incident Reporting and Never Events
A high incident reporting rate is considered to be one of the indicators of a safe
organisation. There has been a notable increase in the total number of
incidents reported with 11396 incidents reported during 2012/13 compared to
10117 in 2011/12.
During the period 1 April to September 2012 the Trust's reporting rate was 5.9
incidents per 100 admissions compared to median of 6.2 for large acute trusts
in the Southwest. The data for 1 October 2012 to 31 March 2013 has not yet
been received from the National Reporting and Learning System (NRLS).
The Trust reported 54 Serious Incidents during 2012/13. The rate of patient
safety incidents that caused serious harm or death reported during the same
time period is 0.81%. Please note this is a different indicator to that included in
the National Quality Indicators section on pages 39/40.
The Trust has an approved process for managing all incidents, including those
classified as 'Never Events' by the National Patient Safety Agency (NPSA).
During the period 1 April 2012 to 31 March 2013, two Never Events occurred at
the Royal Cornwall Hospitals NHS Trust. These are listed below by category
and date:
• Retained vaginal pack: subsequently removed following readmission
(September 2012)
• Wrong sided prosthesis component (1 out of 4) implanted: returned to
theatre and changed for correct prosthesis (March 2013)
The incidents were investigated in line with the Trust's Serious Incident Policy
to identify the root cause and immediate actions taken as a result of the
RCHT 2012/13 Quality Account: Final
20
investigation. All serious incidents are discussed at the Divisional Quality and
Learning Group to ensure organisational wide learning.
The first investigation identified a lack of processes for swab, needle and
instrument counts during a vaginal delivery or suturing. Revised paperwork has
been implemented within the delivery suite to reflect new processes for swabs,
instrument and needle counts.
The second investigation identified that although safety checks are generally
rigorous, they are not strictly standardised and this may have been a factor in
this case. A strict standardised check has been developed and is being
implemented and audited.
Participation in Clinical Audits
During 2012/13, 39 national clinical audits and 9 national confidential enquiries
covered NHS services that the Royal Cornwall Hospitals NHS Trust provides.
During that period the Royal Cornwall Hospitals NHS Trust participated in 93%
of national clinical audits and 100% of national confidential enquiries of the
national clinical audits and national confidential enquiries which it was eligible
to participate in.
• 100% participation in the National Clinical Audit and Patient Outcomes
Programme (NCAPOP)
• 84% participation in “other national clinical audits
The national clinical audits and national confidential enquiries that the Royal
Cornwall Hospitals NHS Trust was eligible to participate in, and for which data
was collected in 2012/13, are listed below alongside the percentage / number
of submitted cases for that audit or enquiry:
Audit/Confidential Enquires
Acronym
Participation
Percentage or
number of cases
submitted
National Confidential Enquiries
Asthma Deaths
Child Health Review
Maternal Infant and Perinatal
Deaths
Alcohol Related Liver Disease
(NCEPOD)
Bariatric Surgery (NCEPOD)
Cardiac Arrest Procedures
(NCEPOD)
Subarachnoid Haemorrhage
(NCEPOD)
RCHT 2012/13 Quality Account: Final
NRAD
Yes
100%
CHR-UK
Yes
100%
Yes
100%
Yes
100%
Yes
100%
Yes
100%
Yes
100%
21
Tracheostomy Procedures
(NCEPOD)
Elective Surgery
(National PROMs Programme)
Suicide and Homicide in Mental
Health
NCISH
Yes
100%
Yes
87%
Not relevant
National Clinical Audit & Outcomes Programme (NCAPOP)
Acute Coronary Syndrome or
Acute Myocardial Infarction
Bowel Cancer
Cardiac Arrhythmia
Carotid Interventions
MINAP
Yes
900 cases
NBOCAP
Yes
100%
HRM
Yes
100%
CIA
Yes
100%
Yes
100%
Coronary Angioplasty
Diabetes (Adult)
ANDA
Yes
100% inpatient
audit. Electronic
solution required
to enable
participation in the
outpatient audit
Diabetes (Paediatric)
PNDA
Yes
100%
Yes
100%
DAHNO
Yes
100%
HF
Yes
Minimum achieved
Heavy Menstrual Bleeding
HMB
Yes
6%
Hip Fracture Database
NHFD
Yes
100%
IBD
Yes
Round 4 data
collection period
still open
NLCA
Yes
100%
NJR
Yes
90%
NNAP
Yes
100%
NAOGC
Yes
100%
Yes
Data collection
ongoing
SSNAP
Yes
100%
NAD
Yes
100%
Epilepsy 12 (Childhood Epilepsy)
Head and Neck Oncology
Heart Failure
Inflammatory Bowel Disease
Lung Cancer
National Joint Registry
Neonatal Intensive and Special
Care
Oesophago-gastric Cancer
Pain Database
Stroke National Audit Programme
(combined Sentinel and SINAP)
National Audit of Dementia
RCHT 2012/13 Quality Account: Final
22
Chronic Obstructive Pulmonary
Disease
COPD
Emergency Laparotomy
Not applicable
Not applicable
Falls and Bone Health
NAFBH
Not applicable
Adult Cardiac surgery
ACS
Not applicable
Congenital Heart Disease
(Paediatric cardiac surgery)
CHD
Not applicable
PICANet
Not applicable
Paediatric Intensive Care
Psychological Therapies
No data collection
this year
No data collection
this year
No data collection
this year
Not applicable
Schizophrenia
NAS
Not applicable
Other national clinical audits
Adult Asthma
BTS
Yes
100%
Adult Community Acquired
Pneumonia
BTS
Yes
Data collection
closes 31 May
ICNARC
CMP
Yes
100%
Bronchiectasis
BTS
Yes
100%
Emergency Use of Oxygen
BTS
Yes
100%
Fever in Children
CEM
Yes
100%
Fractured Neck of Femur
CEM
Yes
100%
Non-invasive Ventilation
BTS
Yes
Data collection
closes 31 May
Paediatric Asthma
BTS
Yes
100%
Paediatric Pneumonia
BTS
Yes
100%
Yes
100%
CEM
Yes
100%
UKRR
Yes
100%
Yes
100%
TARN
Yes
58%
NVD
Yes
100%
NCAA
No
NHPHA
No
Adult Critical Care
Potential Donor
Renal Colic
Renal Registry
Renal Transplantation (NHSBT
UK Transplant Registry)
Trauma
Vascular Surgery (VSGBI
Vascular Surgery Database)
Cardiac Arrest
Health Promotion in Hospitals
RCHT 2012/13 Quality Account: Final
23
Parkinson's Disease
No
Cardiothoracic Transplant
Not applicable
Comparative Audit of Blood
Transfusion
Not applicable
Pulmonary Hypertension
Not applicable
Prescribing Observatory for
Mental Health
POMHUK
No data collection
this year
Not applicable
The reports of 21 national clinical audits were reviewed by the provider in
2012/13 and the Royal Cornwall Hospitals NHS Trust intends to take the
following actions to improve the quality of healthcare provided.
Below are examples of national clinical audits reports published in 2012/13 and
reviewed by the Royal Cornwall Hospitals NHS Trust:
Heart Failure - report published January 2012.
• Results presented to the Governance Committee and the Clinical Audit
and Outcomes Group.
• Overall prognostic drug and echo targets have been met and the Trust’s
performance has steadily improved.
Paediatric Bronchiectasis (British Thoracic Society) - report published April
2012.
• Results presented at the Child Health Audit Meeting in June 2012.
• Most standards have been met.
• Plans to encourage parents to take cough/sputum swab before
antibiotics.
National Paediatric Diabetes Audit - report published September 2012.
• Results presented at a Paediatric Diabetes Away Day in December
2012.
• There has been major investment in the paediatric diabetes service in
2012 that has included additional psychology, diabetic nurse, dietitian
and administration appointments. The first dedicated psychologist for
paediatrics was appointed in 2012.
European COPD (British Thoracic Society) – report published September
2012.
• Results presented at the Respiratory Department Educational Meeting
in December 2012.
• The Trust is a pilot site for the BTS COPD admission bundle to improve
diagnosis, oxygenation, NIV and early pharmacological interventions.
• The Trust is also a pilot site for the BTS COPD discharge bundle to
improve checking inhaler technique, smoking cessation, pulmonary
rehabilitation and community follow up.
• A non-invasive ventilation care pathway has been introduced and is
being piloted.
RCHT 2012/13 Quality Account: Final
24
•
A discharge pathway has been developed by the respiratory Local
Implementation Group for implementation by June 2013.
UK Gynaecology Oncology Surgical Outcomes & Complications
• Results presented at 8th National Cancer Research Institute
Conference in November 2012.
• Work is continuing to further reduce our operative morbidity which is
23% less than national data. Continuing to use techniques such as cell
salvage and assessment of new haemostatic products to reduce blood
loss.
• One of the Trust’s consultants is a recognised national trainer for
courses run by the Royal College of Surgeons and is planning to start a
national course for gynaecology beginning in Truro for the SW trainees.
Myocardial Infarction (MINAP) - report published November 2012
• Results discussed at the Cardiology Department governance meeting in
February 2013.
• The “call to balloon time” is below the national benchmark, therefore the
Trust is working with South Western Ambulance Service (SWAST) to
resolve technical problems with the MOBIMED recording system.
Sentinal Stroke National Audit Programme – Organisational Report published
November 2012.
• The results were discussed at the Operational Stroke Group meeting in
January 2013. Changes have already been made including the
introduction of Early Supported Discharge Team cover for the whole
county. Also faster admission to acute stroke unit has been achieved.
The reports of 139 local clinical audits were reviewed by the provider in
2012/13 and the Royal Cornwall Hospitals NHS Trust intends to take the
following actions to improve the quality of healthcare provided.
Local clinical audits are reviewed at Divisional and Specialty audit and
governance meetings. Examples of actions resulting from local clinical audits
are listed below:
Oxygen prescription and target saturations (National Patient Safety Agency,
Oxygen safety in hospitals, Rapid Response Report)
Report circulated to respiratory team in April 2012.
Actions:
• A respiratory consultant is delivering education sessions to all the
nursing staff.
• E-learning module available to all healthcare professionals.
• Oxygen prescription and practice to be part of Ward performance data.
Audit of paediatric palliative care on Sennen Ward Paediatric Oncology Unit
The report presented at Child Health audit meeting in June 2012.
Actions:
• Regular meetings to be held with the Psychology service.
RCHT 2012/13 Quality Account: Final
25
•
Introduction of an advanced care plan document (“Wishes Document”).
– already used by the local Children’s Hospice.
Constipation in chronic pain patients on analgesic medication – patient survey
Report presented at the Pain Society's annual scientific meeting April 2012 and
the Trust Pain Department meeting May 2012.
Actions:
• The audit suggests that patient awareness and self-management could
be improved. A patient leaflet has been developed.
Parenteral Nutrition
Report presented at the Nutrition Steering Group in August 2012.
Actions:
• Parenteral Nutrition guidelines submitted for consultation and ratification
in May 2012.
• Care plan piloted in May 2012.
• Study days on parenteral nutrition from September 2012.
NICE Technology Appraisal 247 Rheumatoid Arthritis – Tocilizumab
Report presented at the Rheumatology Department meeting April 2012
Actions:
• Report shows compliance with this NICE Technology Appraisal.
• Rheumatoid biologics pathway will continue to be followed and this has
been agreed with the local PCT / prescribing committees.
Trust wide audit of nutrition
Results were discussed at the Nutritional Steering Group in August 2012.
Actions:
• Patient Safety Advisory Group used to disseminate the message and
discuss issues.
• Nutritional Web-ex sessions set up as a learning resource.
Laparoscopic cholecystectomy – complications and readmissions
Report presented at the Surgery audit meeting in May 2012.
Actions:
• 54% of readmissions were for pain therefore information on what to
expect after surgery to be improved.
• Increase awareness of the need for analgesia on discharge.
Paediatric sepsis and timeliness of antibiotics
Presented at the Child Health audit meeting in August 2012.
Actions:
• Development of a local guideline to be produced for the management of
paediatric sepsis.
HIV testing in haematology patients
Presented at the GU Education meeting & the Haematology audit meeting in
July 2012.
Actions:
RCHT 2012/13 Quality Account: Final
26
•
•
•
A checklist system introduced on a new patient proforma for clinic.
Summary of recommendations added to the haematology handbook.
Re-audit planned 6 months after all changes made.
Adult head injury audit at WCH Urgent Care Centre
Results presented to the junior doctors, the nursing manager for WCH Urgent
Care Centre and GP lead for the Urgent Care Pilot in November 2012.
Actions:
• New adult head injury pro-forma from December 2012.
• Implementation of the pro-forma by April 2013.
Anastomotic leak rates following colorectal surgery
Report presented at the Surgery audit meeting in December 2012.
Actions:
• All consultants – lower than nationally accepted standard. Therefore
plan to review 5 years of data to provide further assurance.
Review of nutritional intake for patients with fractured neck of femur in the perioperative period
Presented at the Nutritional Steering Group in December 2012.
Actions:
• Active prescribing of peri-operative supplements introduced.
Research and Development
The number of patients receiving NHS services provided or sub-contracted by
the Royal Cornwall Hospitals NHS Trust in 2012/13 that were recruited during
that period to participate in research approved by a research ethics committee,
was 2133.
Research, Development and Innovation (RD&I) is recognised as core business
for the RCHT as contributing to evidence based practice and improving the
effectiveness of care. RD&I works closely with the Peninsula College of
Medicine and Dentistry (PCMD) and the European Centre for Environment and
Human Health (ECEHH) as part of the research agenda. We also work in
partnership with the Cornwall Partnership Foundation NHS Trust and NHS
Cornwall and Isles of Scilly. This year the Trust continues to strengthen its ties
with industry, working directly with our business partners and contract research
organisations. Raising our profile and increasing income from external sources
has also helped to ensure our patients get access to the latest therapies and
medical devices.
The Trust had 365 active research studies in 2012/13 representing an increase
of 22% on the previous year. The number of participants recruited in 2012/13
was 1870 (network) and 263 (non-network) which shows that there is a trend
towards studies that are registered on the National Institute of Health Research
(NIHR) portfolio.
RCHT 2012/13 Quality Account: Final
27
•
•
285 were network adopted.
o 5 – Dementias and Neurodegenerative Diseases Research
Network (DeNDRoN).
o 12 – Diabetes Research Network.
o 21 – Medicines for Children.
o 147 – National Cancer Research Network.
o 14 – Stroke Research Network.
o 86 – Comprehensive Research Network.
80 were not network adopted.
The number of studies active during 2012/13 is broken down by disease group
below:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
82 – Oncology.
54 – Haematology.
39 – Paediatrics.
20 – Neurology.
18 – Rheumatology.
15 – Obstetrics & Gynaecology.
14 – Diabetes.
14 – Stroke/rehab.
12 – Gastroenterology.
10 – Genetics.
9 – Renal.
8 – General Surgery.
6 – Anaesthetics.
6 – Cardiology.
6 – Dermatology.
5 – Histopathology.
o Diagnostics, Therapeutics & Cancer.
o Mermaid/ Breast.
o Ophthalmology.
35 – Other.
84 studies were approved to commence in 2012/13.
•
•
67 were network adopted.
o 1 – Dementias and Neurodegenerative Diseases Research
Network (DeNDRoN).
o 2 – Diabetes Research Network.
o 7 – Medicines for Children.
o 20 – National Cancer Research Network.
o 4 – Stroke Research Network.
o 33 – Comprehensive Research Network.
17 were not network adopted.
Of the studies approved in 2012/13:
•
58 were non-commercial.
RCHT 2012/13 Quality Account: Final
28
•
26 were commercial.
RD&I continues to work as a member organisation with the Peninsula
Comprehensive Local Research Network (PenCLRN) to ensure all studies are
conducted in accordance with the Department of Health’s Research
Governance Framework for Health and Social Care (2005, 2nd Ed.) and that
clinical trials are conducted in accordance with the Medicines for Human Use
(Clinical Trials) Regulations 2004 (MHRA) and subsequent amendments. Risk
assessment and feasibility are conducted at an early stage in the approvals
process. Systems for identifying delays in giving NHS permissions have been
developed and we are working to a target of less than 30 days. The Trust
continues to use the NIHR Research Passport System for streamlining
approvals for external researchers.
In the last year the Trust has sponsored innovative studies developed by Trust
employees, such as the use of Nintendo Wii™ Sports for improving dominant
arm function after stroke (Twist). The Trust has sponsored a study developed
by the breast cancer surgical team investigating a novel approach to
anaesthetic infusion for pain and shoulder function following mastectomy
(Sublime). Dr Hayes Dalal and Dr Jennifer Wingham have received an NIHR
grant to develop a home-based, nurse facilitated heart failure manual for
patients with heart failure and their caregivers.
Commissioning for Quality and Innovation (CQUIN)
The CQUIN framework is a national scheme that incentivises providers and
commissioners to work together to raise quality and develop innovative
approaches to healthcare provision. It does so by making a proportion of
providers’ income conditional on the achievement - or progress towards
achievement – of jointly agreed goals. These are a mixture of nationally
mandated and locally agreed quality improvement and innovation goals.
CQUIN framework 2012/13
In 2012/13, for the first time, the CQUIN programme comprised two parts,
reflecting the fact that our services are commissioned by two main
commissioning organisations. The first was jointly agreed between RCHT and
NHS Cornwall & Isles of Scilly (NHS CIOS) and the second between RCHT
and the Specialised Commissioning Group (SCG). In both cases, the
percentage of our income coming through the CQUIN route was 2.5%, an
increase from the previous year’s figure of 1.5%.
In our contract with NHS CIOS, just under £7 million was attached to our
CQUIN programme. In our SCG contract, the figure was just under £0.25
million.
Our performance against each goal is shown in our joint scorecard.
RCHT 2012/13 Quality Account: Final
29
Royal Cornwall Hospitals NHS Trust CQUIN SCORECARD 2012/2013
Yellow cells indicate paid milestones
NATIONAL
Venous Thromboembolism (VTE)
95% of all (eligible) adult inpatients are required to have a VTE risk
assessment on admission to hospital, using the clinical criteria of the
national tool.
2
Patient Experience
NATIONAL
1
An improvement on the 2011 score is required in the CQC 2012 Adult
Inpatient Survey composite indicator on responsiveness to personal needs.
Maintenance of the 2011 score will trigger a 50% payment.
3
Dementia Awareness & Diagnosis
Q1
Q2
Q3
Q4
Target
95%
95%
95%
95%
Actual
96.2%
97.2%
97.3%
97.5%
Target
>64.9
Actual
65.7
1. % of all patients aged 75 and over who have been screened following
admission to hospital, using the dementia screening question.
Target
90%
Actual
99.3%
2. % of all patients aged 75 and over, who have been screened as at risk of
dementia, who have had a dementia risk assessment within 72 hours of
admission to hospital, using the hospital dementia risk assessment tool.
Target
90%
Actual
100.0%
3. % of all patients aged 75 and over, identified as at risk of having
dementia, who are referred for diagnosis.
Target
90%
Actual
100.0%
4
NHS Safety Thermometer
NATIONAL
NATIONAL
Improve awareness and diagnosis of dementia, using risk assessment, in
an acute hospital setting. Daycases, electives, transfers and patients with
LoS <72 hours are excluded.
Quarterly submission of monthly-collected data on 4 outcomes (pressure
ulcers, falls,urinary tract infection in those with a catheter, and venous
thromboembolism). Each quarterly dataset must be complete.
5
Avoidable Emergency Admissions
Target
Actual
Q1
Q2
Q3
Q4
100.0% 100.0% 100.0% 100.0%
Progress against indicators relating to avoidable emergency admissions
Target
Q2
Q3
Q4
1. With PCH, re-design 2 pathways that could be more appropriately
managed by a Countywide Acute Care at Home team.
Actual
2. Access to recommended levels of therapy for patients receiving Early
Supported Discharge for Stroke.
Target
Q1
Q2
Q3
Q4
Actual
72.5%
75.4%
77.2%
81.3%
3. Improve medicines management on discharge by reducing the number
of TTA waits over 2 hours.
Target
Q1
Q2
Q3
Q4
Actual
90.1%
88.7%
87.9%
83.0%
Q1
Q2
Q3
Q4
Target
LOCAL
Q1
Joint working has been
undertaken throughout the year,
focussing on cardiology and
respiratory pathways
4. Ensure frail, elderly patients have personalised care plans with
appropriate safeguarding and case management.
Actual
Target
5. Participate with CPFT in the design of an integrated RAID/ psychiatric
liaison service linked to the Acute GP Service and a ‘mental health and
well-being service’.
RCHT 2012/13 Quality Account: Final
Actual
We continue to provide a service
through the two frailty specialist
nurses close to the front door who
integrate with the wider multidisciplinary team there to assess,
respond to immediate need if any
safeguarding matters arise and to
case manage key vulnerable
patients the team's assessment
highlights. They have established
a set of KPIs that records their
case management duties and a
range of interventions. Their
excellent work was recently
acknowledged in the recent South
West Dementia Care 2nd Stage
Peer-Review.
Q1
Q2
Q3
Q4
Although collaboration with CPFT
has continued, the CPFT Board
has not supported its own team's
business case for a new
psychogeriatrician post. The effect
of this has been to bring
discussions to a halt whilst the
CPFT team reviews its strategy.
30
6
Avoidable Elective Admissions
Progress on indicators relating to avoidable elective admissions.
1. Increase the number of terminations of pregnancy undertaken medically
from a baseline of 42%.
2. (a) Increase completion of e-discharge to cover 70% of discharges.
LOCAL
2 (b) Increase timeliness of e-discharge to cover 90% of discharges
3. Participate in regional study of oesophageal doppler monitoring.
Target
44%
46%
48%
50%
Actual
51.4%
60.3%
65.8%
62.6%
Target
Q1
Q2
Q3
Q4
Actual
Target
Actual
36.2%
Q1
75.9%
43.5%
Q2
89.5%
73.0%
Q3
62.3%
82.0%
Q4
70.1%
Q1
Q2
Q3
Q4
Actual
Target
4. Increase the number of patients receiving follow-up by means other than
conventional face-to-face consultation.
SCG
7
Quality Dashboards
To implement the routine use of clinical dashboards in
- Radiotherapy
- Renal Replacement Therapy
- Cystic Fibrosis
- Haemophilia
- Neonatal Intensive Care
Actual
Target
Actual
8
SCG
SCG
Q1
Q2
Q3
Q4
A number of new telephone clinics
have begun this year, as has the
renal results review service. An
activity baseline has been agreed
as part of the AOP process for
2013-14
Q1
Q2
Q3
Q4
A number of new telephone clinics
have begun through the year, up
to and including quarter 3. We are
confident that we will submit
quarter 4 data by the due date of
26 April
Neonatal Intensive Care
8(a). To achieve an increase in the % of low birth weight babies (<33
weeks) fed in part on mothers breast milk at final discharge.
9
No regional study has taken place
but, having benchmarked current
practice we are confident that this
technology has been introduced
appropriately. A statement on our
current position with regards to
the use of this technology has
been incorporated on our
successful pre-qualification bid for
the 2013-14 CQUIN scheme
8(b). To achieve an increase in screening to a target of 90% of babies with
a birth weight of <1500g or a gestation of <32 weeks who undergo initial
Retinopathy of Prematurity (ROP) screening whilst still an in-patient and
screened ‘on time’ or within 7 days.
Target
47%
50%
52%
54%
Actual
64.0%
89.5%
83.3%
90.0%
Target
60%
63%
68%
90%
Actual
94.4%
Target
Q1
Q2
Q3
16.5%
Actual
17.5%
16.4%
17.0%
17.5%
Target
20.0%
40.0%
60.0%
80.0%
Actual
31.8%
43.0%
90.5%
94.4%
94.1% 100.0% 100.0%
Renal Replacement Therapy
9(a). To achieve a minimum 16.5% of dialysis patients (30 in total)
receiving either peritoneal dialysis (including assisted automated peritoneal
dialysis) or home haemodialysis.
9(b). To increase % number of CKD 5 and 4 patients (known to a
nephrologist for 3 months and with progressive deterioration in renal
function) to have a decision made regarding suitability for transplant.
SCG
10 Haemophilia
To increase the numbers of patients' data provided via the Haemtrack
electronic monitoring system.
Target
42%
44%
46%
50%
Actual
56.0%
46.7%
46.7%
66.7%
Once again this year, we have seen real benefits for patients arising directly
from the focus on services that the CQUIN programme encourages. Amongst
these are the following:
RCHT 2012/13 Quality Account: Final
31
•
•
•
•
•
We have sustained the significant improvement in venous
thromboembolism (VTE) screening that we had achieved by the end of
the previous year.
Awareness, screening, diagnosis and treatment of dementia have all
substantially improved after a concerted response to this challenging
national goal.
Use of the NHS Safety Thermometer has been implemented with great
success, giving us valuable information about four avoidable harms to
patients – pressure ulcers, falls, urinary tract infections from catheters
and VTE.
In Neonatal Intensive Care, our performances against both the
breastfeeding on discharge and retinopathy of prematurity goals have
been considerably in excess of the targets that we were set.
In Renal Replacement Therapy, there has been a very significant
increase in the number of patients in the target group who have had a
decision made about their suitability for transplant.
Further details of the CQUIN scheme and the nationally mandated goals are
available electronically at:
http://www.institute.nhs.uk/worldclasscommissioning/pctportal/cq
uin
CQUIN framework 2013/14
For 2013/14, the proportion of income linked to CQUINs will remain at 2.5%.
New this year was the introduction of a set of pre-qualification tests that
required us to demonstrate that we have made progress towards achieving the
aims of Innovation Health and Wealth, Accelerating Adoption and Diffusion in
the NHS, the NHS Chief Executive’s report of December 2012 which set out a
delivery agenda for spreading innovation at pace and scale throughout the
NHS.
As in 2012/13, there are 4 national CQUINs which will account for around 20%
of the programme. These are:
1. VTE: in addition to maintaining our screening performance, we will now
have a target to meet in respect of root cause analysis of a proportion of
those admissions where patients experienced VTE.
2. Patient Experience: replacing the national patient experience survey,
the new Friends and Family Test will be introduced into inpatient wards
and the Emergency Department from April and into maternity wards
from October.
3. Dementia: after spending much of 2012/13 developing the
infrastructure to enable us to deliver this goal, we will continue to embed
the FAIR process (Finding people with dementia, Assessing and
Investigating their symptoms and Referring for support) into our
hospitals.
4. Safety Thermometer: after the successful introduction of the Safety
Thermometer tool, we will now be challenged to make targeted
improvements related to the “4 harms”.
RCHT 2012/13 Quality Account: Final
32
In addition to the national goals, the Trust will agree with both NHS Kernow
and the SCG a range of other, local goals to complete the programme.
How the NHS regulator, the Care Quality Commission, views the quality
of our services
Registration with the Care Quality Commission Essential Standards of
Quality and Safety
The Royal Cornwall Hospitals NHS Trust is required to register with the Care
Quality Commission and its current registration status is unconditional.
The Care Quality commission has not taken enforcement action against the
Royal Cornwall Hospitals NHS Trust during 2012/13.
Care Quality Commission Planned Review Visits
The CQC carried out a responsive review of the Royal Cornwall Hospital on 23
May 2012 between 4pm and 8pm. This followed safeguarding concerns about
the care of vulnerable people who may not be able to speak for themselves. Of
the 5 outcomes assessed the Trust was found to be compliant with 4 and noncompliant with 1; Outcome 13: There should be enough members of staff to
keep people safe and meet their health and welfare needs. The Trust
immediately put in place actions to address the issue raised and was found to
be compliant at a later inspection.
The Trust then received a scheduled inspection by the CQC in November
2012. They visited 3 of the Trusts registered locations: Royal Cornwall
Hospital, West Cornwall Hospital and Royal Cornwall Hospital Headquarters
(this refers to the services we provide in the community for example outpatient
appointments and x-ray departments at community hospitals). The CQC found
the Trust to be compliant with all the outcomes assessed at all locations
visited.
NHS provider periodic review
The CQC did not visit the Trust in 2012/13 as part of its periodic review
programme.
Data Quality
The Trust’s Data Quality Strategy has been extended for a period of six
months to allow a full review and update by the records specialist. The Data
Quality Policy has been recently updated to reflect the organisational changes
in reporting and managing the service and now includes corporate information
systems as well as health information systems, this was following a
recommendation from an internal audit review of data quality.
The Trust Board receives assurance on data quality through the Trust’s
Integrated Governance and Assurance Framework. The Data Quality
RCHT 2012/13 Quality Account: Final
33
Assurance Group reports to the Information Governance Committee. This
group performance manages data quality within the Trust by providing reports
to Divisions and to the Information Governance Committee.
The internal audit review of data quality commissioned by the Executive
Sponsor, made five recommendations:
• Information Asset Owners to become more engaged and own their
systems and information. Root cause analysis to be used when
investigating targets not being met.
• Information Asset Owners to be identified for Maternity and Renal
Systems
• Review resource levels in the Data Quality Team
• Consider implementing an additional module to E-rostering to ensure
sickness management for clinicians is being monitored appropriately
• Identify an Information Asset Owner for ESR and add to the data quality
dashboard for monthly reporting
The Information Asset Owners have now taken responsibility and embedded
monitoring the quality of the data held within their critical systems. Quarterly
meetings continue with members of the Data Quality Assurance Committee.
The Royal Cornwall Hospitals NHS Trust submitted records during 2012/13 to
the Secondary Uses Service (SUS) for inclusion in the Hospital Episode
Statistics (HES) which are included in the latest published data. The
percentage of records in the published data which included the patient’s valid
NHS number was:
• 99.6% for admitted patient care.
• 99.8% for outpatient care.
• 97% for accident and emergency care.
The percentage of records in the published data which included the patient’s
valid General Medical Practice Code was:
• 100% for admitted patient care.
• 100% for outpatient care.
• 99.2% for accident and emergency care.
Information Governance Toolkit attainment levels
The Royal Cornwall Hospitals NHS Trust Information Governance Assessment
Report overall score for 2012/13 was 72% and was graded Green.
Clinical Coding Error Rate
The Royal Cornwall Hospitals NHS Trust was subject to the Payment by
Results (PbR) clinical coding audit during the reporting period by the Audit
Commission. The error rates reported in the latest published audit for that
period for diagnoses and treatment coding (clinical coding) were:
Gynaecology accuracy
• Primary diagnosis - 97.3%.
RCHT 2012/13 Quality Account: Final
34
• Secondary diagnosis - 97.9%.
• Primary procedure - 91.8%.
• Secondary procedure - 100%.
Within this section of the audit there was a 10.1% change in Healthcare
Resource Group's (HRGs), this would have put the Trust in the worst
performing 25% of Trusts compared to last year’s national performance. The
Trust has a comprehensive clinical coding audit programme in place which
includes individual coder audits, specialty audits, benchmarking audits and
change process audits. All coding errors are fed back to clinical coders and
where necessary further clinical coding training is carried out.
Hip accuracy
• Primary diagnosis - 100%.
• Secondary diagnosis - 97.7%.
• Primary procedure - 97%.
• Secondary procedure - 90.6%.
Within this section of the audit there was a 3% change in HRG's, this would
have put the Trust in the best performing 25% of Trusts compared to last
year’s national performance.
RCHT 2012/13 Quality Account: Final
35
National Quality Indicators.
Where possible the national data reflects acute trusts only.
The value and banding of the summary hospital-level mortality indicator
(“SHMI”) for the trust
July 2011 – June 2012
October 2011-September 2012
National Data
average lowest highest
1.00
0.71
1.26
RCHT
1.03
National Data
average
lowest highest
1.00
0.68
1.21
RCHT
1.04
The percentage of patient deaths with palliative care coded at either
diagnosis or specialty level for the trust
July 2011 – June 2012
October 2011-September 2012
National Data
average lowest highest
18.6
0.3
46.3
RCHT
16
National Data
average
lowest highest
19.20
0.20
43.30
RCHT
0.104
National Data
average
lowest highest
0.085
-0.020 0.156
16.50
RCHT
0.078
The trust’s patient reported outcome measures scores for varicose vein
surgery – average health gain (lower scores are better)
April 2009 - March 2010
April 2010 – March 2011
National Data
average lowest highest
0.094
0.150 -0.002
RCHT 2012/13 Quality Account: Final
RCHT
0.092
National Data
average
lowest highest
0.091
0.155 -0.007
The Royal Cornwall Hospitals NHS Trust has taken the following
actions to improve this score and so the quality of its services,
by continuing to review both national and local mortality data
ensuring that appropriate actions are taken where indicated.
RCHT
The trust’s patient reported outcome measures scores for groin hernia
surgery – average health gain
April 2009 - March 2010
April 2010 – March 2011
National Data
average lowest highest
0.082
0.011 0.136
The Royal Cornwall Hospitals NHS Trust considers that this data
is as described for the following reasons
• The data is validated nationally, and
• Correlates with the Trust’s internal data
The Royal Cornwall Hospitals NHS Trust considers that this data
is as described for the following reasons
• The data is validated nationally, and
• Correlates with the Trust’s internal data
The Royal Cornwall Hospitals NHS Trust has taken the following
actions to improve this score and so the quality of its services,
by ensuring all PROMS data is reviewed by the relevant
specialties and participating clinicians.
RCHT
0.090
36
The trust’s patient reported outcome measures scores for hip
replacement surgery – average health gain
April 2009 - March 2010
April 2010 – March 2011
National Data
average lowest highest
0.411
0.287 0.514
RCHT
0.376
National Data
average
lowest highest
0.405
0.264 0.503
RCHT
0.411
The trust’s patient reported outcome measures scores for knee
replacement surgery – average health gain
April 2009 - March 2010
National Data
average lowest highest
0.294
0.172 0.386
April 2010 – March 2011
RCHT
0.330
National Data
average
lowest highest
0.298
0.176 0.407
RCHT
0.291
The percentage of patients aged 0 to 14; readmitted to a hospital which
forms part of the trust within 28 days of being discharged from a hospital
which forms part of the Trust.
April 2009 - March 2010
April 2010 – March 2011
The Royal Cornwall Hospitals NHS Trust considers that this data
is as described for the following reasons
• The data is validated nationally, and
• Correlates with the Trust’s internal data
National Data
average lowest highest
10.25*
0.00
22.93
The Royal Cornwall Hospitals NHS Trust intends to take the
following actions to improve this score and so the quality of its
services, by working together with the Cornwall Health and
Social Care community to reduce hospital readmissions.
RCHT
9.97
National Data
average
lowest highest
10.15*
0.00
14.34
RCHT
9.33
The percentage of patients aged 15 or over; readmitted to a hospital
which forms part of the trust within 28 days of being discharged from a
hospital which forms part of the Trust.
April 2009 - March 2010
National Data
average lowest highest
11.61*
0.00
15.97
RCHT 2012/13 Quality Account: Final
RCHT
11.70
April 2010 – March 2011
National Data
average
lowest highest
11.42*
0.00
15.33
*National average for all NHS Trusts in England. Lowest and
highest figures relate to acute Trusts only
RCHT
11.21
37
The trust’s responsiveness to the personal needs of its patients. National
In-patient results
2010
2011
National Data
average lowest highest
67.3
56.7
82.6
RCHT
67.3
National Data
average
lowest highest
67.4
56.5
85.0
RCHT
64.9
The percentage of staff employed by, or under contract to, the trust
during the reporting period who would recommend the trust as a
provider of care to their family or friends.
2011
2012
National Data
average lowest highest
65
33
96
RCHT
38
National Data
average
lowest highest
65
35
94
RCHT
43
The Royal Cornwall Hospitals NHS Trust considers that this data
is as described for the following reasons
• The data is validated nationally, and
• Correlates with the Trust’s internal data
The Royal Cornwall Hospitals NHS Trust intends to take the
following actions to improve this score and so the quality of its
services, by listening and acting upon all patient feedback.
The Royal Cornwall Hospitals NHS Trust considers that this data
is as described for the following reasons
• The data is validated nationally, and
• Correlates with the Trust’s internal data
The Royal Cornwall Hospitals NHS Trust intends to take the
following actions to improve this score and so the quality of its
services, by continuing with our Listening into Action initiative
and improving the health and wellbeing of our staff.
The Trust notes the low scores on this important indicator.
The percentage of patients who were admitted to hospital and who were
risk assessed for venous thromboembolism.
July – September 2012
National Data
average lowest highest
93.8
80.9
100.0
RCHT 2012/13 Quality Account: Final
October – December 2012
RCHT
97.2
National Data
average
lowest highest
94.3
84.6
100.0
RCHT
97.3
The Royal Cornwall Hospitals NHS Trust considers that this data
is as described for the following reasons
• The data is validated nationally, and
• Correlates with the Trust’s internal data
The Royal Cornwall Hospitals NHS Trust has taken the following
actions to improve this score and so the quality of its services,
by continuing to ensure all our patients are risk assessed on
38
admission, including targeted action where performance is
below 100%.
The rate per 100,000 bed days of cases of C.difficile infection reported
within the trust amongst patients aged 2 or over
April 2010 – March 2011
April 2011 – March 2012
National Data
average lowest highest
29.6
0
71.8
RCHT
22.7
National Data
average
lowest highest
21.8
0
51.6
RCHT
19.8
The Royal Cornwall Hospitals NHS Trust considers that this data
is as described for the following reasons
• The data is validated nationally, and
• Correlates with the Trust’s internal data
The Royal Cornwall Hospitals NHS Trust intends to take the
following actions to improve this score and so the quality of its
services, by reviewing antibiotic prescribing by both hospital
doctors and GPs and compliance with all infection, prevention
and control policies.
The number of patient safety incidents reported within the trust
April – September 2011
October 2011 – March 2012
National Data
RCHT
National Data
average lowest highest
average
lowest highest
2676.47 88
8461
3335
2833.36
66
8778
The rate of patient safety incidents reported within the trust
April – September 2011
RCHT
The Royal Cornwall Hospitals NHS Trust considers that this data
is as described for the following reasons
• The data is validated nationally, and
• Correlates with the Trust’s internal data
3499
The Royal Cornwall Hospitals NHS Trust intends to take the
following actions to improve this score and so the quality of its
services, by continuing to encourage a reporting and learning
culture within the organisation.
October 2011 – March 2012
National Data
RCHT
National Data
RCHT
average lowest highest
average
lowest highest
6.63
2.13
19.25
5.59
6.92
0.94
21.71
5.86
The number of such patient safety incidents that resulted in severe harm
or death.
April – September 2011
National Data
average lowest highest
RCHT 2012/13 Quality Account: Final
October 2011 – March 2012
RCHT
National Data
average
lowest highest
RCHT
39
20.05
0
160
23
21.25
0
144
20
The percentage of such patient safety incidents that resulted in severe
harm or death.
April – September 2011
October 2011 – March 2012
National Data
average lowest highest
0.79
0.00
7.01
RCHT 2012/13 Quality Account: Final
RCHT
0.69
National Data
average
lowest highest
0.82
0.00
3.58
RCHT
0.57
40
PART THREE – REVIEW OF THE TRUST’S QUALITY PERFORMANCE
Patient Safety
Obstetrics and Gynaecology Service Review
The Trust published five independent reports on its Obstetrics and
Gynaecology Service on 28 February 2013. The independent reports were
commissioned following concerns about some of the treatment and care
provided by one former Consultant - Mr K R Jones.
The five independent reports were:
• The interim Independent Case Note Review of Mr Jones’ patients
• Royal Cornwall Hospitals NHS Trust Organisational Learning Review
• NHS Cornwall and Isles of Scilly Organisational Learning Review
• Rapid Response Review commissioned by NHS South of England to
assess the current Obstetrics and Gynaecology service
• Patients Association Review of recent patient experience in
gynaecology services
Both the Chairman and Chief Executive of the Trust apologised unreservedly
to the women affected.
Martin Watts, Chairman (28 February Trust press release)
“On behalf of the Trust I wish to unreservedly apologise to those women and
their families for the pain, distress and anxiety caused by the practice of former
Obstetrics and Gynaecology Consultant Mr Rob Jones. The Independent
Organisational Learning Review commissioned by the current Trust Board
confirms that concerns identified about some of Mr Jones’ practice should have
been addressed with more vigour and urgency.”
“We must fully acknowledge the mistakes made – apologise and learn from
them – whilst also recognising the significant progress continuing to be made
by our dedicated staff to secure better and safer care for the people of
Cornwall and the Isles of Scilly.”
Lezli Boswell, Chief Executive (28 February Trust press release)
“I want to thank patients and staff who did speak out and raise concerns about
the practice of Mr Jones. Their courage, persistence and candour has led to
where we stand today.”
“The women who have spoken out have enabled other women to seek and
receive the treatment and support they deserve from RCHT. I believe this is a
significant moment for us and marks a challenge to change the culture of
RCHT.”
“We will implement all of the recommendations from the independent reports
and work tirelessly to rebuild trust and improve the services we provide.”
RCHT 2012/13 Quality Account: Final
41
The interim Independent Case Note Review identified that in 2275 of the 2396
(94.95%) case notes reviewed there was no evidence of harm or need to recall
women to clinic. 52 women (2.17%) under the care of Mr Jones were found to
have suffered complications as a result of surgery - all of whom were already
receiving follow up support and treatment. 69 women (2.88%) were felt to be at
risk of harm either through failure to manage their case appropriately (1.88%)
or because the quality of recording keeping did not permit the necessary
assurances to be given (1%).
58 women have been recalled for clinical assessment and their outcomes will
be known by the end of March 2013 when the final Independent Case Note
Review will be published.
Lower Segment Caesarean Section Surgical Site Infection Surveillance
(SSI)
Surveillance of lower segment caesarean sections (LSCS) commenced in
January 2012. Between January 1st and March 31st 2012 the data collected
highlighted a Surgical Site Infection rate of 11.2%. This was compared to the
national rate of 9.86% and despite the validity of this comparison (very few
hospitals perform post-discharge surveillance and the more thoroughly this is
performed, the more infections will be identified) a complete review of pre, intra
and post-operative practice was undertaken.
The following recommendations were made
Pre operatively:
• Patient Education.
• Shower before surgery.
• If hair removal is necessary – clip do not shave.
• Comply with antibiotic policy – antibiotics to be given 15 – 30 minutes
pre incision.
• Skin prep – use 2% chlorhexidine and allow to dry rather than wiping
dry.
Post operatively:
• Hydrofilm to be used rather than cosmopore as wound dressing choice.
• Hydrofilm to be left insitu for a minimum of 48 hours.
• Patient Education.
The Divisional Manager, Tissue Viability Consultant Nurse and Wheal Fortune
ward manager attended a meeting to discuss and action the recommendations.
The SSI rate for April-June 2012 highlighted an improvement of 9.8% and
between July and September 2012 the infection rate following LSCS was
3.5%. Due to such a considerable improvement it was decided that a further
quarter of surveillance should take place to ensure consistency. An SSI rate of
2.8% showed a further decline from October to December.
RCHT 2012/13 Quality Account: Final
42
SSI Rate Following LSCS 2012
12
SSI Rate %
10
8
6
4
2
0
Jan.-March 2012 April-June 2012 July-Sept. 2012 Oct.-Dec. 2012
Clinical Effectiveness
Lung Cancer Services
The Trust participated in the Improving Lung Cancer Outcomes Project
(ILCOP), which is delivered by the Royal College of Physicians and funded by
the independent charity The Health Foundation. ILCOP seeks to raise the
standards of Multi-Disciplinary Teams (MDTs) by partnering them with other
MDTs from two hospitals and enabling them to share their approaches and
successes, and to identify solutions to their different challenges.
This process – in which the team from Cornwall worked with colleagues from
the Royal United Hospital Bath NHS Trust – identified four areas where
changes have led to improvements:
1. The Trust made the case to secure additional lung Clinical Nurse
Specialists (CNSs), meaning that more patients who have this important
support from the very first stages of their patient journey, as well as
during treatment and care. Patient satisfaction surveys show that
patients hugely value this.
2. The Trust introduced a new technology – Endobronchial Ultrasound
(EBUS) – which is used to take biopsies from the lung in a less invasive
and safer way. Patients have the procedure as a day case, rather than
coming in for surgery, reducing length of hospital stay. The unit is also
evaluating the impact on histological confirmation and referral for
treatment.
3. Specimens are now handed over in person to pathology by a clinical
team member rather than sent via the central hospital portering system.
Audit results show that this has improved communication and speeded
up the time taken from biopsy to reporting, with results available in time
for the MDT meeting almost without exception.
RCHT 2012/13 Quality Account: Final
43
4. Improvements in the quantity and quality of data captured have been
made thanks to ‘bouncers’. These people watch as data administrators
input their data, during the MDT meeting and stop the MDT
conversation if anything has been missed to enable the administrator to
catch up.
The positive impact of the resultant service changes implemented during 2010
and 2011, are illustrated by the improvements in performance.
National lung cancer audit results for Royal Cornwall Hospitals NHS Trust
compared with respective national standard
In March 2013 MHP Health Mandate published “Quality at a glance - using
aggregate measures to assess the quality of NHS hospitals”. MHP Health
Mandate is a multi-award-winning specialist health policy and communications
consultancy. The report focussed on the overall quality of NHS hospitals and
the quality of lung cancer services.
A number of sources were used to assess the quality of specific lung cancer
hospital services:
• Waiting times for people referred with suspected lung cancer
• The National Cancer Patient Experience Survey 2011/12
• The National Lung Cancer Audit 2012
• National Cancer Peer Review reports
RCHT was rated as the 2nd highest performing Trust for its lung cancer
services.
Junior Doctors in Training
Postgraduate Medical Education is subject to rigorous quality checks and
these take the form of an annual Deanery visit, annual General Medical
Council (GMC) Trainee Survey, Local Education Provider visits from each
Specialty School e.g. Medicine, Foundation, Surgery etc and end of placement
trainee surveys. From these data streams an action plan is formulated for
RCHT by the Peninsula Deanery and this plan is ratified by the GMC. The
Director of Medical Education works in collaboration with the Divisional and
Specialty leads in order to address action points that are coded on a red,
amber and green basis. Sign off is by the Deanery and GMC, and is the
measure by which the NHS Litigation Authority (NHSLA) ratings for supervision
of doctors in training are recommended by the GMC for the Trust.
RCHT 2012/13 Quality Account: Final
44
The GMC also reviews good practice at each Trust and in 2012 RCHT was
commended for three areas of best practice; more than any other Local
Education Provider in the Peninsula.
Generic Skills – Good Practice
Generic skills teaching is a six week rolling programme consisting each week
of three hours of protected teaching time. In a small group of ten trainees, it
focuses on areas of the Foundation Year 1 curriculum better taught in this
setting. It covers the non-clinical professional attributes of ‘the good doctor’ as
outlined in the GMC guide of this name. It also includes sessions on career
planning, practical skills taught in the clinical skills laboratory by a clinical skills
tutor, and acute care training using simulation. The sessions were initially
started by Dr Cate Powell shortly after Foundation training was introduced
nationally, and continue to be led by Drs Julie Blundell and Rachel Todd who
are the Trust tutors for F1 training, and Dr Clare Moser who is the Clinical
Skills tutor.
We have been proactive in delivering teaching requested by the junior doctors
and the trust, tailoring it to meet the requirements of the Foundation curriculum.
Delivery of the teaching has been via mixed media, allowing maximum time for
hands on practise on our models and manikins, and ample opportunity to ask
questions. Trainees enjoy the sessions as they provide a relaxed and informal
teaching environment away from the clinical setting. They also provide an
opportunity to meet fellow trainees and to share and reflect on their clinical
experiences. They have received excellent feedback from the trainees, in
addition to very positive recognition by the Deanery and the GMC.
Junior Doctors Management Group
The Junior Doctors Group was established in 2010. Membership of the group
includes representatives from human resources, postgraduate education,
junior doctors at all levels, rota coordinators, British Medical Association (BMA)
and medical staffing. The purpose of the committee is to inform junior medical
staff of Trust, contractual and postgraduate education issues that impact upon
them. It also allows the junior medical staff a voice at senior management
level and gives the opportunity for a two-way honest feedback.
Another initiative established in 2012 was ‘Team Talk’ delivered to junior
medical staff twice monthly at the Postgraduate Centre. A Trust Board
representative attends postgraduate education teaching sessions to give the
junior doctors a presentation on current Trust performance and also to receive
feedback from junior doctors about any concerns they have. We hope that this
addresses a common concern raised by trainees, regarding the interface
between NHS management and the delivery of patient care. This initiative has
received positive feedback from the trainees.
Simulation Training
Over the past three years Simulation has been developed to deliver training for
junior doctors in a classroom environment in the Postgraduate Education
Centre. Approximately £250,000 of high fidelity simulation equipment has
RCHT 2012/13 Quality Account: Final
45
been funded by the SHA and Deanery through successful bids to the
innovation funds by Dr Cate Powell, Director of Medical Education and the
education team.
Over the past six months a highly successful and innovative pilot has been
running, bringing simulation training to the point of care in the RCHT wards,
clinics and operating theatres. Using high fidelity computerised patient
manikins, scenarios that mimic potential emergency clinical situations are
acted out in the clinical setting by the multi-disciplinary team. This type of
training is likened to that received by pilots and has been shown to improve
team working and communication, thus reducing potential errors and improving
patient safety. 2000 hours of direct staff training has been delivered, and this
project demonstrates that point of care simulation enables delivery of multiprofessional training to nurses and Allied Health Professionals (AHPs)
alongside doctors of all grades on the wards. Simulations have been run in 16
wards and clinical areas to date, including West Cornwall and St Michael’s
Hospital, with plans to reach even more staff across the Trust. The project has
met with great enthusiasm from all staff involved and momentum is growing
rapidly as more staff members request to become involved. Strong
governance pathways are becoming established, with training developed to
address issues raised in critical incident reports. Feedback from simulations
also ensures that potential patient safety issues are identified and addressed
pre-emptively.
The GMC have particularly commended the multi-disciplinary obstetric team
training at the Royal Cornwall Hospital provided by an obstetric speciality
clinical faculty on a monthly basis.
Training in Obstetric Multi-Professional Emergencies (TOME) runs monthly
and is currently provided for all clinical staff that care for the pregnant women
of Cornwall and the Isles of Scilly. This includes hospital-based and
community-based midwifery staff, maternity nurses, obstetricians, GP trainees
and obstetric trainees, anaesthetists and anaesthetic trainees, operating
department practitioners, paramedics, GPs and medical students undergoing
clinical attachments on the Delivery Suite.
The training fulfils the mandatory criteria for the multi-disciplinary obstetric
team in the management of specified obstetric emergencies and has been
recognised in the recent review (February 2013) by the Clinical Negligence
Scheme for Trusts (CNST). The CNST assessment awarded Maternity Clinical
Risk Management Standards at Level 3. Multi-disciplinary obstetric
emergencies training is additionally recommended by the Royal College of
Anaesthetists, Royal College of Obstetricians and Gynaecologists and the
Royal College of Midwives through the triennial CEMACH (Confidential Enquiry
into Maternal and Child Health) and 2006-2008 CMACE (Centre for Maternal
and Child Enquiries) reviews.
Simulation team training is included as part of the TOME course and
comprises multi-disciplinary groups undertaking two high fidelity scenarios;
management of the collapsed mother and management of massive obstetric
RCHT 2012/13 Quality Account: Final
46
haemorrhage, alternated with two low fidelity actor/staff-simulated scenarios for
the management of cord prolapse and management of eclampsia and severe
pre-eclampsia.
The TOME simulation training programme in the Royal Cornwall Hospital has
previously featured in the BMA publication Quality Time, December 2010. Dr
Cathy Ralph described, at interview, how the significant contribution of
dedicated multi-professional simulation training contributed to improvement
and maintenance in provision of high quality care in the management of
obstetric emergencies. The recent award of CNST Level 3 to Maternity
Services at RCHT included acknowledgment of the positive impact of the
TOME programme.
Cornwall Vascular Unit
In the past year, vascular surgery has emerged as a new independent
specialty distinct from its origins within general surgery. In 2005 the Royal
Cornwall Hospital was the first hospital in the southwest to provide a separate
vascular surgical service, with a dedicated on-call rota for emergencies, and it
remains one of the few units to provide more than 50% of out-patient activity at
outreach clinics throughout the county, designed to minimise inconvenience for
patients. It has also led the region in the introduction of many new techniques
and working practices over the last 15 years. However the geography and
population of Cornwall is such that, in its present configuration, the vascular
service deviates from the "ideal" configuration recommended by the Vascular
Society of Great Britain and Ireland, despite its exceptional achievements in
the following areas:
Carotid Surgery
Surgery to remove disease from the carotid arteries in the neck (carotid
endarterectomy), is a key treatment in some patients suffering from strokes
and transient ischaemic attacks ("mini strokes"). National recommendations
advocate prompt referral and surgery following symptoms. As one of the final
steps on the multidisciplinary stroke care pathway in Cornwall, the Vascular
Unit provides a prompt service with rapid access to appropriate surgery and
excellent patient outcomes.
Comparative outcomes from the UK Carotid endarterectomy audit round 4
(2012), published by the Royal College of Physicians
Nationally agreed
quality metric
Vascular Unit RCHT
Patients receiving
Carotid surgery within
48hrs of referral to
vascular surgery
RCHT 2012/13 Quality Account: Final
17%
Southwest region
average
13%
National Average
15%
47
Patients undergoing
carotid surgery within 14
days of referral to
vascular surgery
90%
68%
65%
Patients undergoing
carotid surgery within 14
days of initial symptom
72%
56%
49%
30 day stroke and death
rate
2%
3%
2%
Aortic Aneurysms
The Southwest Peninsula Abdominal Aortic Aneurysm (AAA) screening
programme, hosted by the Trust, has been fully operational for 18 months,
offering screening for aortic aneurysms to all men in their 65th year. A number
of aneurysms have been detected by this programme and successfully treated
at RCHT and Derriford Hospitals. The Cornwall Vascular Unit continues to
develop its services to maximise the number of patients who can have their
aneurysms repaired by keyhole surgery (EVAR), and at the present time over
70% of planned operations are undertaken by EVAR. There are also strong
links with centres of excellence in Birmingham and London to provide access
to keyhole surgery for the small number of patients whose aneurysms require
more complex EVAR treatments. For a number of years the mortality rate
following elective aneurysm surgery in Cornwall (currently 2.4%) has been
below the 3.5% target set by the Quality Improvement Programme of Vascular
Society as achievable for vascular surgical units in the UK by 2014.
Varicose Veins
Patients attending the hospital have had access to keyhole treatments for
varicose veins since 2006, and most patients eligible for varicose vein
treatments in Cornwall are now treated with endothermal ablation, which is a
local anaesthetic, "walk in, walk out" treatment undertaken at West Cornwall
and St Michael’s Hospitals. These treatments are not readily available to NHS
patients in many parts of the country, although the National Institute for Health
and Care Excellence (NICE) will recommend this as the first choice treatment
for suitable varicose veins when it publishes its latest guidance on the
management of varicose veins in July 2013. The Vascular service in Cornwall
has been some years ahead of the rest of the country in bringing the most
appropriate treatments to patients at RCHT.
The future
The aim of the vascular unit is to ensure that high quality, innovative, and
clinically appropriate treatments continue to be available to the local
population, and provided in Cornwall wherever possible. Our efforts in the
immediate future will be concerned with ensuring that this aim is achieved to
ensure that the RCHT remains a provider of high quality vascular surgical
services.
RCHT 2012/13 Quality Account: Final
48
Audiology
Background
The Audiology Service is based in Trelawny Wing at the Royal Cornwall
Hospital within the Audiology and ENT (Ear Nose and Throat) Outpatients
department. It is a joint Adult/Children’s service employing 39 staff and
delivered around 30,000 outpatient spells in 2012/13.
Staff are very much part of a wider multidisciplinary team comprising ENT,
Aural Care, Hearing Therapy, Volunteers, Teachers of the Deaf, Social
Workers for the Deaf and Hearing Impaired and Environmental Equipment
Officers able to advise, provide and install assistive listening devices
equipment as needed. This integrated approach is recognised as an area of
excellence, allows for good communication between teams and personalised
care for all patients accessing the service.
The Audiology service is delivered across a wide variety of locations across
Cornwall and the Isles of Scilly including schools, health centres and
community hospital sites. A domiciliary and volunteer visiting service is also
provided.
Objectives achieved 2012/13
1. Improved Pathway for Children’s Hearing Service.
GPs and other health professionals refer approximately 2000 children with
suspected hearing loss to hearing assessment clinics (HACs) each year.
Clinics run across the County at 17 community clinic venues providing a local,
easily accessible service for families. Children are reviewed and a care
pathway followed for:
• Newborn Hearing screen ‘at risk’ babies.
• Initial hearing assessment from routine referral.
• Monitoring of existing conditions.
• Onward referral to other services e.g. ENT
• Advice to parents regarding the detection and management of childhood
hearing loss and the effects on early language development.
In June 2012 responsibility for HAC’s transferred from Child Health to the
Audiology service, bringing together management of the whole hearing loss
pathway for the first time. From the Newborn Hearing Screening Programme
(NHSP), school screening and paediatric Audiology service through transition
to Adult hearing services. Co-ordination of the pathway is already delivering
family friendly improvements, which will continue into 2013/14 driving efficiency
through rationalisation of appointments, and wider skill mix of teams.
2. Qualification of Adult Hearing Services under Any Qualified Provider (AQP).
The advent of extending patient choice through the introduction of Any
Qualified Provider (AQP) tender processes for Adult Hearing Services in
2012/13 presented a number of challenges and opportunities. Although already
delivering the majority of service outcomes described in the AQP specification
RCHT 2012/13 Quality Account: Final
49
further improvements in quality have been made to ensure the service is fully
compliant with AQP.
Main targets achieved:
• Shorter waiting times for Adult Hearing Services.
o Maximum of 20 days from referral to assessment.
o Maximum of 25 days from assessment to fitting.
o Hearing aid follow-up after hearing aid fitting within 10 weeks.
Adul ts waiting longer than 20 days for Assessment and 25 days for
fitting of Hearing Aids
400
350
300
250
200
150
100
50
0
•
•
•
•
•
Assessment
Fitting
Redesign of existing and development of new care pathways for
patients on an AQP pathway.
Development of new information reporting and data collection tools to
meet AQP monthly monitoring requirements.
Increased capacity for hearing aid follow-up with the introduction of a
new telephone follow-up service to start in 2013/14 for eligible patients
to avoid patients traveling unnecessarily to hospital for follow-up.
Consultation with staff to extend working hours to the weekend to
improve access for patients.
Registered with Improving Quality In Physiological diagnostic Services
(IQIPS).
3. Audiology Service for West Cornwall Hospital (WCH).
The creation of a new clinical area has seen the introduction of regular
Audiology clinics to WCH. Clinics are currently running 4 days a week but will
move to 5 days a week from 1 April 2013. Patients who historically have had to
travel either to St Michaels Hospital or to the Royal Cornwall Hospital in Truro
for hearing aid assessment, hearing aid fitting, maintenance and repair can
now have this delivered locally providing care closer to peoples’ homes.
The improved accommodation has also provided an excellent environment for
the local children’s hearing assessment clinic which has now been moved from
the Bellair clinic in Penzance.
RCHT 2012/13 Quality Account: Final
50
4. Hearing Therapy Team.
The Audiology service also includes the provision of Hearing Therapy for
patients with tinnitus or more complex hearing needs. The tinnitus service has
been reviewed to reduce the number of DNA's and also to introduce a more
robust outcome measure (Tinnitus Functional Index). There is close liaison
with other agencies e.g. Adult Social Care, Hearing Loss Cornwall, West of
England Cochlear Implant Programme, to ensure the best care for people with
the most complex hearing needs.
Key initiatives 2013/14
• Marketing of AQP service.
• National accreditation for Adult Hearing Services.
• Implementation of extended opening hours.
• Review of DNA rates across Children’s Hearing Services.
• Specialist commissioning Children’s Hearing Services and Implantable
Devices.
• Service line costing and unbundling of tariff.
Laparoscopic Colorectal Surgery
Bowel cancer is the third most common cancer in Cornwall with more than 350
people affected every year. This means that at any one time about 1,300
people living in Cornwall are being treated for the disease. Demand for the
service is increasing both as a result of bowel cancer screening and 2 week
wait referrals.
The Royal Cornwall Hospital achieves above National average results for the
proportion of patients discussed at MDT (100%) and patients seen by a
specialist nurse (99.7%). We do the most cancer operations in the Peninsula.
RCHT 2012/13 Quality Account: Final
51
Cancer operations performed
250
200
150
All Colorectal cancers
Rectal cancers
100
50
0
RCH
Exeter
Plymouth
Torbay
Barnstaple
Bowel cancer ranks second as a leading cause of avoidable cancer death in
the UK accounting for 16,259 deaths in 2010 but the post-operative mortality at
the Royal Cornwall Hospital is below the national average.
The very latest laparoscopic (keyhole) surgery is undertaken at the Royal
Cornwall Hospital. There are six specialist colorectal surgeons all of whom are
experienced in laparoscopic surgery. Laparoscopic bowel resections are
undertaken in state of the art dedicated laparoscopic theatres.
In the National Cancer Patient Experience Survey (2011/12) Royal Cornwall
Hospital staff scored above the national average in many areas: on giving a
complete explanation of purpose of test, what was involved in the test, written
information about the test, a complete explanation of the results in an
understandable way, written information on their type of cancer and about the
operation, taking patients views into account and being able to discuss worries
with staff, staff working well together, ensuring patients did not feel that they
were a set of cancer symptoms, and taking part in cancer research. Comments
made include:
“The doctor who operated on me was very careful”
“The Surgeon and Specialist Care Nurses were very good. They always
had the time to help with queries.”
“I am very happy with the way I have been looked after by all Hospital
Doctors and Nurses and would like to thank Treliske Hospital and the
Cornwall NHS. Thank you.”
“Everyone involved in my cancer treatments and care were well
informed and knew exactly what was going on and were easy to
contact.”
RCHT 2012/13 Quality Account: Final
52
To promote bowel cancer awareness in conjunction with a National campaign
3 nurses from the specialist bowel ward and a Consultant Colorectal Surgeon
undertook radio interviews, published newspaper reports and trust press
releases, gave talks and met with various organisations including Lions, Rotary
Club, University of the 3rd Age (U3A) and Cornwall County Council. They
raised more than £15000 through their fundraising events all of which went
toward the charity Beating Bowel Cancer.
The Royal Cornwall Hospital actively participates in research contributing to
many clinical trials. In addition the department has contributed to research
through presentations and publications at regional and international meetings.
Bariatric and Metabolic Surgery
Obesity is a serious health issue in Cornwall as it is in the rest of the UK. Half
the population are overweight and 30% are obese. Obese patients are at
greatly increased risk of a range of illnesses including diabetes, hypertension,
heart disease, joint failure, breathing difficulties and cancer. These illnesses
cost the NHS over £5 billion per year. At any age the mortality rate of obese
patients is double that of the non-obese population and their life expectancy is
reduced by an average of 9 years.
Most overweight people try to control their weight by dieting and lifestyle
measures, and some patients are treated by their GP’s with medication.
Unfortunately, for most obese patients with a Body Mass Index over 35 these
measures are unsuccessful. For patients above 18 years of age whose Body
Mass Index exceeds 40, or those with a Body Mass Index over 35 who have
developed medical illnesses linked with obesity, bariatric surgery is the only
treatment likely to be successful.
Bariatric and Metabolic surgery describes a number of procedures intended to
help patients lose weight, and more importantly to cure conditions linked to
obesity such as Type 2 Diabetes and high blood pressure. The most common
operations performed are the Gastric Band procedure, the Roux-en-Y Gastric
Bypass procedure and the Gastric Sleeve Procedure.
Gastric Bypass Operation
Gastric Band Operation
These operations are performed in specially commissioned dedicated bariatric
surgery units. In July 2009 the Medical Weight Management and Bariatric
RCHT 2012/13 Quality Account: Final
53
Surgery Service was commissioned and established at the Royal Cornwall
Hospitals NHS Trust. The team includes specialist nurses, dieticians, surgeons
and anaesthetists to provide complete care for these patients. All operations
are performed by keyhole surgery in newly installed purpose built state of the
art laparoscopic theatres.
Around 100 – 150 operations are performed annually. Two surgeons perform
operations, and the service is to be expanded with the appointment of a third
surgeon later this year
The results following this surgery at RCHT are very impressive, and match
those achieved elsewhere in the world. Patients having a gastric band have
lost 49% of their excess weight within 30 months after their operation. After
gastric bypass operations patients have lost 70% of their excess weight within
a year.
Excess Weight Loss after Bariatric Surgery
80%
70%
60%
50%
40%
30%
20%
10%
0%
Gastric Band
RCHT 2012/13 Quality Account: Final
Ga stric Bypass
54
Similarly impressive results have been achieved in resolving the medical
conditions of obese patients: 92% of diabetic gastric bypass patients had their
Type 2 Diabetes cured within 3 months of surgery. 47% of diabetic gastric
band patients had their Type 2 diabetes cured 6 months after surgery. Marked
improvements or cure of other obesity related conditions including arthritic joint
pain, high blood pressure, high cholesterol levels or breathing difficulties were
also achieved.
As a result of bariatric surgery our patients have a much better quality of life
and life expectancy, and the demands placed upon the NHS have decreased
markedly.
Patient Experience
National Accident and Emergency (A&E) / Emergency Department (ED)
Survey
During 2012, a questionnaire was sent to patients who had attended an NHS
A&E / ED during January, February or March 2012 in England. Responses
were received from 406 of the Trust’s patients.
The Trust’s scores compared to other NHS Trusts
Score
Theme
Comparison with other Trusts
9.2/10
Travel by ambulance
6.2/10
Reception and waiting
8/10
Doctors and nurses
7.9/10
Care and treatment
8.1/10
Tests
8.1/10
Hospital environment and
facilities
6.2/10
Leaving the ED Department
6.5/10
Overall views on experience
RCHT 2012/13 Quality Account: Final
55
The department reviewed the survey results in full and identified a number of
actions including linking in with other initiative already underway:
• The rebuild of the Emergency Department (ED) as part of the Clinical
Site Development Plan (CSDP).
• The Listening into Action (LIA) ED workstream.
National Inpatient Survey
Between September 2013 and January 2013 a questionnaire was sent to
patients who had been admitted as an inpatient during June, July or August
2012 for each NHS Trust in England. Responses were received from 436 of
the Trust’s patients.
The Trust’s scores compared to other NHS Trusts
Score
Theme
Comparison with other Trusts
8.1/10
The Emergency / A&E
Department
9.3/10
Waiting list and planned
admissions
7.7/10
Waiting to get to a bed on a
ward
8.1/10
The hospital and ward
8.6/10
Doctors
8.1/10
Nurses
7.5/10
Care and treatment
8.3/10
Operations and procedures
7/10
Leaving hospital
4.9/10
Overall views and
experiences
The Trust has worked hard to improve the experience of our patients resulting
in improved scores for 8 out of the 10 question areas.
RCHT 2012/13 Quality Account: Final
56
We will be concentrating on the following themes in 2013/14:
• Admission through the Emergency Department.
• Improving ward environments.
• Emotional support and communication with patients.
• Discharge processes.
Early Supported Discharge (ESD) for stroke
The initial ESD pilot began in November 2011 covering West Cornwall.
Following the success of this pilot the service continued and was
commissioned to cover the whole county with the East team in operation from
August 2012.
The new county-wide service facilitates early discharges from hospital for
patients with mild to moderate symptoms post stroke and provides specialist
stroke rehabilitation (Occupational Therapy, Physiotherapy and Speech and
Language Therapy) in the home environment. Rehabilitation is focussed
around patient specific goals and can be provided for up to 6 weeks.
The service comprises two teams, one in the East and one in the West of the
county. Referrals are accepted from the acute stroke unit at Royal Cornwall
Hospital and the community stroke rehabilitation units in Bodmin and
Camborne.
The NHS Accelerating Stroke Improvement (ASI) Programme set a target of
40% of stroke patients to be supported by ESD services on discharge from
hospital. Since August 2012 when both ESD teams became operational we
have supported an average of 42% of stroke patients.
The graph illustrates the estimated bed days saved by the service over the
year with an average of 3 bed days saved per patient.
Bed Days Saved
66
70
60
60
51
50
41
36
35
40
28
30
30
28
22
19
16
20
10
0
Apr-12
Jun
RCHT 2012/13 Quality Account: Final
Aug
Oct
Dec
Feb
57
NICE Stroke Quality Standard 10 states that ‘All patients discharged from
hospital who have residual stroke-related problems are followed-up within 72
hours by specialist stroke rehabilitation services for assessment and ongoing
management’. Since April 2012 97% of stroke patients discharged with ESD
have been seen at home within 72 hours, of this figure 88% have been
followed up within 24 hours.
The ESD service works closely with the Short Term Enablement and Planning
service (STEPs) run by Cornwall Council. The STEPs teams provide reenablement packages of care. Collaborative working across agencies allows
earlier discharges from hospital and facilitates greater improvements in the
patient’s functional independence. On discharge from the ESD service 61% of
patients who originally received a STEPs package do not require a long term
package of care.
The ESD service aims to provide 45 minutes of therapy for a minimum of 5
days a week in line with the NICE Stroke Quality Standard 7. For 2012/13 the
service has been 81% successful in providing therapy for 45 minutes or over.
Therapy Provided
7%
12%
45 Minutes and Over
Less Than 45 Minutes
Required but Not Delivered
81%
Feedback on the service from patient and carer satisfaction questionnaires has
been positive;
“I am a lot more mobile. I am a lot more confident doing things and am a
lot happier.”
“I feel that the ESD team have been extremely supportive, helpful and
informative. They have been very attentive to [my relative’s] needs and
RCHT 2012/13 Quality Account: Final
58
have interacted with him well. He always looked forward to their visits
and will miss the team.”
“Absolutely outstanding care – really impressed by [the] team’s
professional attitude.”
Young Peoples takeover event in Sexual Health
As part of the National Children’s and Young people’s takeover day initiated by
the National Children’s Commissioner, Sexual Health involved young people in
service change and design. Seven young women students from St Austell
College attended from 10 am to 3pm.
Aims of the day
• For a group of young people to experience and then comment on the
patient journey.
• For us to discover how we can improve the service for young people.
• For young people to gain an insight into how services run and are
improved.
They spent most of the morning experiencing the patient journey from initial
call to getting an appointment through to receiving a positive result.
Following this they participated in a number of activities to ascertain their views
and ideas for the service.
The feedback on their experience in the clinic was positive
• Staff attitude, knowledge and respect for them was high.
• Language used and explanations given was at the correct level.
• The overall experience was ‘comfortable, friendly, relaxed’.
• They were given choices and enabled to make decisions.
Suggestions for improvement were
• More community awareness of services offered.
• Better information available on the ‘clinic experience’ or ‘what to expect’.
• The waiting area and initial ‘coming into the building’ was the only
experience that was daunting, we discussed ways of improving that i.e.
music, screens, décor, magazines.
Feedback relevant to other organisations
• Need for increased relationship and sex education in schools.
• Prefer to have ‘professionals’ delivering sexual health messages in
schools & colleges.
• Outside of the clinic there is a general lack of clear information on
contraception, enjoying sex and what is normal.
The suggestions and feedback are being used to improve our service and
community awareness. Feedback relevant to other services has been shared
with a positive response. Partnership work is underway to increase awareness
RCHT 2012/13 Quality Account: Final
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of services offered for young people, vulnerable groups and those who are
hard to reach.
Involvement and Stakeholder Engagement
As an aspirant NHS Foundation Trust we are increasingly looking to our
membership as the focus for engagement and involvement and integrating this
work with Patient Ambassadors and speciality patient groups.
Public membership is now at 5,241 and the staff membership is at 5,255 (20
opt out members). The target for public members by December 2013 is
10,000 which will give a full membership of over 15,000 members including
staff.
To support this target there is a Membership and Engagement Committee
which has been created by the Shadow Council of Governors. Their first
meeting will be in May 2013 and will debate the strategy and plans for
membership recruitment and engagement initiatives.
Due to Governor elections, training and support, there has been limited
recruitment activity. This will continue from April 2013 including a new
membership leaflet distribution and recruitment activity using outpatient
appointment information. The Governors held their first Shadow Council of
Governors meeting on 7 March with a training day on 14 March.
There has been an improvement in member involvement as a new monthly
bulletin has been created which is emailed to all members along with links into
health interest areas, recruiting the following numbers for hospital groups:
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60
Group
Bowel Cancer Patient Group
Beathe Easy Group
Cancer Patient Network
Cardiac Patient Group
Dermatology Patient Group
Diabetes Patient Group
Hospital Radio Volunteering
Mermaid Patient Group
Patient Ambassadors
Prostate Cancer
RCHT Volunteering
Readers Panel
Research
Stepping Stones Patient Group
Learning Disability information
Interested
1
4
3
7
3
7
5
3
9
1
8
7
3
0
4
In addition there is a new reader’s panel in which members can confidentially
read and improve hospital information, ranging from leaflets to website content.
They have worked on the membership leaflet, an easy read version of this
leaflet, a children’s questionnaire and the readers panel recruitment leaflet
itself.
To continue improving the engagement with the membership there are a
number of projects being developed such as the bedside folder, health talks for
members, Royal Cornwall Hospital open day and Governor engagement
activity.
The Trust has continued to enjoy excellent working relationships with both
Cornwall and Isles of Scilly Local Involvement Networks (LINks). As well as
responding to formal and informal requests for information, Trust staff have
participated with various task groups including safe hospital discharge
arrangements from West Cornwall Hospital to the Isles of Scilly by plane now
that the helicopter service has been discontinued. During the past year LINks
have been focussing on the transition from LINks to Healthwatch which took
place on 1st April 2013. The existing LINk staff hope that the newly appointed
Board of Directors for Healthwatch will wish to continue with the joint health
and social care meetings. These meetings proved to be of value in providing a
more joined up approach to health and social care priorities and issues that
matter most to the people of Cornwall.
In line with the Trust’s 5 year rolling strategic plan, the Patient Experience
Group meets on a monthly basis to oversee the implementation of the Patient
Experience and Public Involvement Strategy. Part of the strategy involves the
recruitment of Patient Ambassadors; twelve Ambassadors were recruited and
trained in December 2012. These Ambassadors are working closely with the
Divisions to support them in various projects which benefit from patient and
public involvement; for example: looking at streamlining the patient’s journey
through Clinical Imaging departments making it more logical and time saving;
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61
involvement in the Clinical Site Development Plan and the move of acute
services to Trelawny wing; involvement in changes to patient areas within the
Theatre and Anaesthetics Division; membership of the Patient Information
Group and the Readers Panel, reviewing all patient information to assess
clarity and accessibility.
The Child Health department is currently recruiting young people from schools
to become Patient Ambassadors; they will be looking at the patient
environment, patient surveys and menus. The department is also involved with
the ‘Kinda Magic’ project which aims to ensure that as many voices of people,
who in the past, have found it hard to contribute to patient experience feedback
(e.g. those with cognitive and communication impairment, learning disability
and young children) are included in surveys that get reported to the Trust
Board. Alongside this is the exploration of mechanisms that ensure feedback
is heard at the right level and responded to.
An example of involving children and young people in service change and
design was the ‘Takeover day’ held on 23rd November. Young people from
two primary schools and the 6th form of Camborne Academy worked on
changes to the menus, the patient experience feedback form and the décor of
the children’s’ unit. The young people involved have now met with the relevant
managers involved and any changes made are being fed back to the young
people and their teachers.
Statements from Healthwatch, Health Overview and Scrutiny Committees
and Clinical Commissioning Groups
Kernow Clinical Commissioning Group
Kernow Clinical Commissioning Group is pleased to have the opportunity to
comment on the Quality Account 2012/13 for the Royal Cornwall Hospitals
Trust (RCHT), and welcomes the approach the Trust has shown in developing
and setting out its plans for quality improvement. There are routine processes
in place with RCHT to agree, monitor and review the quality of services
throughout the year covering the key quality domains of safety, effectiveness
and experience of care.
The Quality Account presents an overview of a wide range of quality
improvement work being undertaken. We are particularly pleased to see the
Boards commitment to quality as demonstrated through the Board work on the
Listening into Action Programme. We welcome the Trust Boards commitment
to implement the recommendations of the five review reports in respect of
Gynaecology, published February 2014.
The report presents a fair reflection of progress in 2012/13 and we can confirm
the information presented in the Quality Account appears to provide a
balanced account which is accurate and fairly interpreted, from the data
collected. In terms of the performance against the 2012/13 CQUIN goals the
indicators were achieved in full.
We note the positive improvements Royal Cornwall Hospitals has made in:
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•
•
•
Meeting the Infection Prevention and Control standards
Recognition of the work in the Improving Lung Cancer Outcomes project
The GMC commendation for three areas of best practice in junior
doctors training
Kernow CCG looks forward to working with the Trust throughout the year to
deliver high quality services to patients, especially:
•
•
•
•
•
Patient Safety
working with partners to identify and prevent the admission of high risk
patients to hospitals
improving the discharge experience reducing unnecessary discharge
delays
the focus on the CARE campaign
the focus on staff wellbeing
We are pleased to see that the priorities chosen for 2013/14 have been
identified with key stakeholder involvement. Kernow CCG would wish the Trust
to focus on these areas although not selected as a priority:
•
•
•
•
Improving patient experience through the single point of access and
reducing ambulance delays
It is good to see the work undertaken to reduce harm to patients through
the implementation of the national safety thermometer and is therefore
disappointing that the Trust has requested a reduced target from the
national recommended 50% reduction in relation to pressure ulcers
Delivering the action plans for improvement in Gynaecology services
following the review report of February 2013
Developing and delivering action plans for improvement in cancer
services in response to the Cancer Services Peer Review report
Cornwall Health and Adults Overview and Scrutiny Committee
During the consultation for this Quality Account, Cornwall Council was in a preelection period prior to the 2013 local elections. Whilst the election has now
taken place there is to be a new Council governance structure which will
include alterations to the health scrutiny function.
In the period April 2012 to April 2013 the Health and Adults Overview and
Scrutiny Committee has regularly scrutinised Royal Cornwall Hospital Trust.
This scrutiny will be undertaken by the new Health and Social Care Scrutiny
Committee in the future municipal year.
It is expected that Royal Cornwall Hospital Trust will be required to report to
the Health and Social Care Scrutiny Committee, its progress against the stated
future priorities for quality improvement and performance indicators contained
within this Quality Account.
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Healthwatch Cornwall
Do the priorities of the provider reflect the priorities of the local population?
Healthwatch Cornwall is alarmed to see that the number of ambulances waiting
over 30 minutes at RCH is the highest it has been for 2 years. This is
particularly alarming considering the measures that the Trust has put in place
to ease patient flow.
Furthermore, Healthwatch Cornwall notes from the April 2013 Board report that
4791 patients spent more than four hours waiting at either the Royal Cornwall
Hospital or West Cornwall Hospital, which sits above the RCHT standard of
seeing 95% of patients within the four hour time frame. Recent patient
feedback given to Healthwatch Cornwall reflects these figures with patients
having to wait too long to be seen.
Discharge and the flow of patients remains a priority for Healthwatch Cornwall,
as it was for its predecessor, LINk in Cornwall as it remains one of the most
prominent issues which patients tell us about. Last year, LINk in Cornwall
recommended that RCHT monitor the quality of discharge as perceived by
patients and carers (not just by themselves) and should contribute to work on a
cross-agency basis, with an agreed measure of quality in this area.
Healthwatch Cornwall would like to see further detail on how quality of
discharge will be measured.
Healthwatch Cornwall would like to echo LINK’s previous statement,
particularly in light of the Overview & Scrutiny Committee’s recent Discharge
Enquiry Day and its emphasis on cross-agency working. Healthwatch Cornwall
would recommend that there is a member of staff who has the overall
responsibility of patient flow, as discharge is frequently delayed or the quality of
discharge suffers without having someone responsible.
Healthwatch Cornwall would like to see more detail around the reasons for the
difficulty in getting patients triaged, and the delayed ambulances. Likewise,
further detail around the areas of improvement would be welcomed.
Healthwatch Cornwall is pleased to see the re-launch of the “When will I go
home?” booklet, which was developed and championed by LINK in Cornwall.
However, Healthwatch Cornwall would like to see clearer measures of how
discharge is monitored.
Regarding pages 55-57 of the account on Patient Experience, Healthwatch
Cornwall (like its predecessor LINk in Cornwall) wishes to contribute to
development of the methodology that RCHT adopts to measure patient
experience. We have asked to have discussions about the Patient Survey and
its content so that statutory providers are collecting patient feedback in a
standardised way. We note that Patient Related Outcome Measures (PROMs)
are in use in parts of the Trust, although this does not appear to be referred to
in the Quality Accounts.
Patient opinions should be sought (1) by asking questions that have been
agreed in advance by the widest possible group of people, including
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Healthwatch Cornwall, and (2) by looking at ways of collecting data that allow
patients time for reflection on their experience, perhaps after discharge and the
completion of their course of treatment. This might include electronic means
(for example the Meridian programme, currently in use in CPFT).
We at Healthwatch Cornwall look forward to contributing to this process, which,
when coordinated with consumer views from across the health and social care
services, will assist the Health and Wellbeing Board in its task of influencing
the commissioning of services that patients truly value, and in whose design
patients will feel they have played a part.
Is the Quality Account clearly presented for patients and the public?
Healthwatch Cornwall finds the Quality Account to be presented in an attractive
easy to read style and explains information in a way that will be accessible to
the public, with abbreviations explained.
Isles of Scilly Health Overview and Scrutiny Committee
The Isles of Scilly Health Overview and Scrutiny Committee welcomes the
opportunity to contribute to these Quality Accounts.
We would like to see continued work to improve the patient experience of
discharge from mainland acute settings back to the islands. Work needs to be
done in individual wards to ensure knowledge of the particular circumstances
relating to travel and accommodation for patients from the islands. The work to
ensure appointment flexibility for islanders has improved pathways for patients
and this must continue particularly in the light of travel disruption over the last
winter. Continued commitment to transport issues from the Trust is welcomed.
In order to overcome some of these issues the islands would like to see better
take up of technology for consultation and assessment. We would like to see
greater commitment to the pilot project set up by local health partners. We
believe that technology can improve patient experience and is a more efficient
use of resources.
We would also like greater engagement with the Trust in strategic thinking
about how to maximise the total health and care resources on the islands to
commission and provide the best services for islanders.
Formalised feedback from the appointed Governor will be critical to ensure
consistent and constructive dialogue with the Trust.
Healthwatch Isles of Scilly
Thank you for forwarding your Quality Account. It is a comprehensive and
informative document and will provide a useful reference in the coming year.
We are pleased to see that improving the discharge experience for patients
continues to be a priority. RCHT’s Patient Transport Service worked closely
with IOS Council and Link4Scilly in 2012 on a number of travel and transport
issues and was instrumental in reviewing and reorganising procedures after
the cessation of the helicopter service. Their knowledge and understanding of
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our particular transport needs is a valuable resource and one which we would
like to see all ward staff refer to in discharge planning.
Healthwatch Isles of Scilly has been able to take forward LINk’s good working
relationship with the Trust and we continue to raise issues directly with key
contacts in the organisation. We are looking forward to re-establishing our
Medical Travel-IOS joint working group and the Joint Liaison Group co-chaired
with Healthwatch Cornwall. IOS involvement with RCHT has been further
strengthened by the election of a Foundation Governor and the appointment of
a Patient Ambassador.
Trust response to comments from third parties
The Trust is grateful to stakeholders and third party organisations that helped
to shape our Quality Account for 2012/13
We will continue to work with our colleagues in health and social care to
reduce ambulance handover delays and the length of time patients wait to be
seen in the Emergency Department. Rebuilding of the Emergency Department
is underway with completion of the first two phases expected in late July. This
includes additional trolley bays and a dedicated Paediatric treatment area to
improve the flow through the department and the resulting patient experience.
A procurement process is underway for an electronic solution for capturing
patient experience e.g. touchscreen kiosks which we aim to have in place by
the end of March 2014.
Statement of Directors' Responsibilities in Respect of the Quality
Account
The directors are required under the Health Act 2009, National Health Service
(Quality Accounts) Regulations 2010 and National Health Service (Quality
Account) Amendment Regulations 2011 and 2012 to prepare Quality Accounts
for each financial year. The Department of Health has issued guidance on the
form and content of annual Quality Accounts (which incorporate the above
legal requirements).
In preparing the Quality Account, directors are required to take steps to satisfy
themselves that:
•
the Quality Accounts presents a balanced picture of the Trust’s
performance over the period covered;
•
the performance information reported in the Quality Account is
reliable and accurate;
•
there are proper internal controls over the collection and reporting of
the measures of performance included in the Quality Account, and
these controls are subject to review to confirm that they are working
effectively in practice;
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•
the data underpinning the measures of performance reported in the
Quality Account is robust and reliable, conforms to specified data
quality standards and prescribed definitions, is subject to appropriate
scrutiny and review; and the Quality Account has been prepared in
accordance with Department of Health guidance.
The directors confirm to the best of their knowledge and belief they have
complied with the above requirements in preparing the Quality Account.
By order of the Board
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Independent Auditors’ Report
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