Quality
ACCOUNT
2012/13
1
Contents
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68
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76
Values
Chief Executive’s statement
3
Statement of directors’ responsibilities
Priorities and improvement
Better complaints management
Review of services
Participation in clinical audit
Research
Goals agreed with commissioners
Commissioning for Quality and Innovation 2012/13
What others say about the RNOH
Redevelopment of the Stanmore site
Specialist Orthopaedic Alliance
How we ensure a legacy of continuous innovation and quality improvement
Data quality
Information Governance
NHS Outcomes Framework
Review of quality performance
Infection control
Management and leadership
Our Quality Ambitions
Publishing and Involving stakeholders in the Quality Account
Statement from NHS North Central London
Statement from Harrow Links
RNOH Charity
Trust Opinion
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
Quality Account 2012/13
4
The Royal National Orthopaedic Hospital (RNOH/the Trust) is the UK’s leading
specialist orthopaedic hospital. We provide a comprehensive and unique
range of neuro-musculoskeletal healthcare, ranging from acute spinal injuries
to orthopaedic medicine and specialist rehabilitation for chronic back
sufferers.
RNOH also plays a major role in teaching. Over 20% of all UK
orthopaedic surgeons receive training at the RNOH. Our patients
benefit from a team of highly specialised consultants, many of whom
are nationally and internationally recognised for their expertise.
We enhance our clinical effectiveness by working in partnership with University College London
and in particular UCL’s Institute of Orthopaedic and Musculoskeletal Science (IOMS), based on
the Stanmore campus. The IOMS, together with the RNOH, has a long track record of innovative
research leading to new devices and treatments for some of the most complex orthopaedic and
musculoskeletal conditions.
Our strategic aims/objectives
1
Maintaining and developing orthopaedic specialisation- providing the scale and range
of tertiary sub-specialist orthopaedic clinical activity befitting an international
orthopaedic centre of excellence.
2
Expanding the evidence base that we deliver high quality clinical services – providing
clinical activity to a standard that demonstrates services are safe, effective and provide
the best possible experience. This includes timely referral to treatment access to services
and transport accessibility to our sites for patients, many of whom will have significant
mobility impairment.
3
Building academic strength – working in partnership with UCL, a world leading
university and the UCL Partners Academic Health Sciences Network.
4
Expanding our external profile and focus – building an international reputation for
clinical, operational and academic expertise supported by working in partnership with
other NHS and independent health care providers.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
5
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Our Trust Values guide us in delivering the highest standards in
patient care. They underpin our behaviours and strengthen our
relationships with each other
Our values
Patients first,
always
Excellence,
in all we do
Trust, honesty
and respect,
for each other
Equality,
for all
•
•
•
•
•
•
Protecting patients’ rights to courtesy and dignity
Treating patients as individuals and with compassion
Responding to patients’ needs and expectations
Providing a clinically safe environment
Achieving positive clinical outcomes
Rigorous monitoring and maintenance of high standards
• Practice based on evidence, education and research
• Working across departments and professional boundaries to
achieve Trust-wide goals and targets
• Rewarding and celebrating excellence
• Maximising the benefits of partnerships
• Paying attention to detail
• Striving for excellence through collaboration and research
•
•
•
•
•
•
•
•
•
Challenging inappropriate behaviour from patients or colleagues
Being transparent and open with each other
Asking for help when we need to
Contributing to the team
Being constructive rather than blaming
Listening more than telling
Maintaining confidentiality for patients and colleagues
Speaking well of, and supporting each other
Empowering staff to achieve their potential
•
•
•
•
•
•
•
•
Reaping the benefits of diversity
Ensuring equitable care for all our patients
Designing services to meet the needs of all our patient groups
Challenging prejudice and discrimination
Valuing the diversity of ideas, roles and backgrounds
Ensuring fair and consistent employment practice
Celebrating difference and achievement at all levels of the Trust
Patients first
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
7
Chief Executive’s statement
This Quality Account provides evidence of our commitment to continuous Quality Improvement
at RNOH. It contains information about the quality of our services, the improvements we have
made during 2012/13 and sets out our key priorities for the forthcoming year.
8
During 2013/13 we worked hard to deliver the targets which relate to patient experience and
clinical outcomes. We exceeded the national access targets in admitting more than 90% of
patients requiring treatment within 18 weeks of their referral to the RNOH. We exceeded the
non-admitted target of 95% consistently throughout the year, and we also delivered an average
of 100% against the 93% national target, ensuring our cancer patients were seen within two
weeks of referral. The RNOH is working hard to minimise the number of cancelled operations
and this work will continue in 2013/14 by enhancing our scheduling and finalising operating
lists in a timelier manner.
The number of patients completing our real time patient feedback questionnaires in wards has
increased slightly and we have tried to rationalise questions to decrease any burden on patients.
For the second year running results show an improvement in the courtesy of our doctors and
nurses, scoring 93% and 95% respectively. The experience our patients have whilst under our
care is very important to us and the information we gather from patient feedback allows us to
focus on areas which require improvement. The ‘Friends and Family’ test was introduced
nationally in April 2013 but as we were an early implementer, our patients were involved in the
test from October 2012. Over 50% of our patients responded to
the questionnaire and the
results appear positive.
Following on from this,
the RNOH will be able
to benchmark against
other Trusts later in
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The RNOH achieved 100% in February and March 2013 on VTE (venous thromboembolism)
assessment compliance. Any DVT’s (deep vein thrombosis) or PE’s (pulmonary embolism)
developing within the Trust are investigated through Root Cause Analysis in order for any required
change in practice to be identified.
In 2011/12, I said our aim for 2012/13 was to continue to deliver low infection rates, reduce the
number of pressure ulcers, improve our medicines management and enhance the quality of our
patients’ experience. We have seen improvements in all of these areas and as a Trust we pride
ourselves on the quality of the care we provide. Our infection rates remain low and we have had
no MRSA bacteraemia recorded for over 3 years. To maintain and support the high standard of
care we deliver, we are in the process of strengthening our infection control service to ensure
patients are monitored for one year post surgery when necessary. Because the RNOH is a tertiary
referral centre for patients with spinal injuries and provide ‘cradle to grave’ care, we have seen
an increase in the number of patients transferred to us from other Trusts and the community for
specialist care of significant pressure ulcers. Accepting these referrals impacts negatively towards
our Safety Thermometer scores but, significantly, pressure ulcers developing during admission
were less than 0.1% of all admissions in 2012/13, reduced from 0.2% in 2011/12, and
significantly less than the 1.5% reported nationally. Our drug errors are monitored by a senior
team weekly and actions taken to reduce the risk of further similar errors taken swiftly.
The Trust received a visit from the Care Quality Commission (CQC) in January
2013. We were declared compliant with all the essential standards except
one, which relates to safety and suitability of premises. It’s long been
recognised that the Stanmore site is overdue comprehensive
redevelopment and there has been considerable enabling works
undertaken in the last year to clear sections of the site in preparation for
phase one of the new hospital development. This work will address the
concerns of the CQC. The Board will continue to move toward the RNOH
becoming a foundation trust in 2014 thereby enabling the RNOH to remain
a stand-alone specialist organisation undertaking innovative research and
delivering world-class clinical care to our patients.
I confirm to the best of my knowledge that the information contained in this report
is accurate.
Rob Hurd Chief Executive
9
Statement of directors
reponsibilities
10
The directors are required under the Health Act 2009 to prepare a Quality
Account for each financial year. The Department of Health has issued
guidance on the form and content of annual Quality Account (which
incorporates the legal requirements in the Health Act 2009 and the National
Health Service (Quality Account) Regulations 2010 (as amended by the
National Health Service (Quality Account) Amendment Regulations 2011).
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
In preparing the Quality Account, directors are required to take steps to
satisfy themselves that:
The Quality Account presents a balanced picture of the Trust’s performance over the period
covered
• The performance information reported in the Quality Account is reliable and accurate.
• There are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account and these controls are subject to review to
confirm that they are working effectively in practice.
• The data underpinning the measures of performance reported in the Quality Account is
robust and reliable, conforms to specified data quality standards and prescribed definitions,
and is subject to appropriate scrutiny and review; and
• The Quality Account has been prepared in accordance with Department of Health
guidance.
The directors confirm to the best of their knowledge and belief they have complied with the
above requirements in preparing the Quality Account.
By order of the Board.
28 June 2013
Professor Anthony Goldstone CBE,
Chairman
28 June 2013
Rob Hurd,
Chief Executive
11
Priorities and improvements
12
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Following consultation with patients, staff and key stakeholders, we
identified three key priorities for 2012/13.
The outcomes were as follows:
Priority 1
Continue to monitor avoidable infection and maintain current low levels
Outcome
13
The infection prevention and control audit programme has been enhanced with new audits
being introduced in 2012-13 covering the following areas:
•
•
•
•
•
•
•
•
•
•
Environment
Ward/departmental kitchens
Handling and disposal of linen
Waste management
Departmental waste handling and disposal
Safe handling and disposal of sharps
Management of patient equipment (general)
Management of patient equipment (specialist areas)
Hand hygiene
Clinical practices
•
•
•
•
•
•
The use of personal protective equipment
hort term urethral catheter management
Enteral feeding
Care of peripheral intravenous lines
Care of short term non-tunnelled central venous catheters
Isolation precautions
These audits generate reports which wards are able to print for their infection prevention and
control boards for immediate feedback to staff. They also generate action plans for areas that
require attention and ensure better staff engagement and a rapid corrective response to
infection prevention and control issues. (Please see page 64)
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
13
Priority 2
14
Increase the impact of pre-operative assessment
Outcome
During 2012/13 the Trust started a process to reorganise pre-operative assessment. The aim is
for patients to be assessed at the time they are listed for surgery.
This will improve the patient experience by requiring fewer visits to outpatients. It will also
bring pre-operative assessment earlier into the patient pathway. This will give more time to
address medical issues, without impacting on the date on which surgery is scheduled. This
should have two benefits: it will improve planning and scheduling and it will reduce the
number of patients cancelled on the day of surgery, for medical reasons.
In order to achieve this we have looked at conversion rates at surgical out patients and we are
working with the pre assessment staff to make sure the job planning of nursing and medical
time in pre assessment fits demand.
We continue to improve the quality of pre-assessment during 2013/14. A particular problem is
presented by patients who are on a cancer treatment pathway, who present with new or
complex cardiac problems. Referral to back to their GP is time consuming and often
unsatisfactory. We are discussing, with the Royal Free Hospital, setting up a rapid access clinic
that would give a consultant cardiology opinion with appropriate investigations, without delay
to definitive oncological treatment.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
Priority 3
Dementia screening of patients over 75 years of age
15
Outcome
In July 2012 the Trust started screening patients at pre-assessment for cognitive impairment
with the intention of ensuring that patients with cognitive impairment experience appropriate
care while in hospital here and contributing to meeting the national priorities of early
diagnosis of Dementia.
Following a positive screen patients are flagged up with their GP who is encouraged to
facilitate a local specialist Memory clinic assessment for them, and in the meantime we work
to ensure their needs are met during the planned inpatient stay. The next phase of the project
is to refine how best to meet the needs of patients with cognitive impairment during their
hospital stay.
Progress is demonstrated in the graph below.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
April
May
June
July
August
September
October
November
December
January
February
March
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
16
During 2012/13 we continued to build on the quality improvements previously
reported as well as starting new programmes. Some of these have been initiated at
corporate level and others by local clinical teams, reflecting a Trust-wide culture that
supports quality improvement. Some of our quality highlights and challenges from
the year were:
Improved Access
National 18 week access targets were achieved in 2012/13, with 96% of non-admitted
patients and 92% of admitted patients being treated within 18 weeks against targets of 95%
and 90% respectively.
It continues to be a central aim of the Trust to continue to meet access targets during 2013/14
and further improve access to our services for patients.
Admissions Lounge
The ‘Admissions Lounge concept’ was trialled for 8 weeks during the summer of 2012 and
became a great success. The lounge was developed by a small team of Nursing Staff, within
the surgical directorate. Since then we have developed plans to refurbish a brand new
Admissions lounge as a part of the hospital refurbishment.
The objective of the Admissions Lounge is to create a single point of access and to establish a
professional area to safely admit Adult admissions Mon-Sat. The facility provides a comfortable
waiting area for those patients awaiting transfer to their allocated Ward.
The lounge is staffed by the Admissions team from 6:30-15:00hrs. We have a comfortable 17
seated area in which Patients can wait for their pending transfers. We have a wide screen
plasma TV for the Patients entertainment and an assortment of books and magazines
available.
The lounge is within close proximity to 2 x disabled toilets and has a cold water fountain and
hot drink machine for Patients use, if permitted.
The facility also boasts two clinical areas, which accommodate the Admissions Sister and the
Admissions Nurse the area can also be utilised for medical Staff who require privacy and
confidentiality for Patient consultation. We have the necessary equipment for basic
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
observations and access to phlebotomy equipment if required along with documentation
resources and access to ICE and Insight.
Each Patient is greeted by a member of our team, their ID will be checked and a hospital wrist
band will be applied. The Admissions Nurse will then see the Patients in the private clinical
room, where all necessary nursing documentation will be completed and the expected
Discharge date will be provided. There will be the opportunity to carry out basic observations
and monitoring.
During this time it is likely that the patient would be seen by their Consultant or their team as
well as the Anaesthetist. Once the necessary reviews have been completed the patients will be
transferred to the admitting ward in preparation for theatre. If the bed is not immediately
available, patients may be asked to wait in our seating area. Here the admissions team keep
patients up to date with the progress of their ward allocation.
Clinical Key Performance Indicators (KPI’s)
The Trust piloted and implemented clinical KPI’s in 2012/13.
During 2013/14 the clinical KPI’s will help the RNOH continue to achieve improvement in the
services it provides by:
•
•
•
•
Identifying areas of best practice
Focusing on continuous improvement
Delivering improved outcomes
Taking action to improve health services
Friends and Family Test
The Trust implemented the Friends and Family test on all inpatient wards in October 2012. The
Friends and Family Test is a simple, comparable test which, when combined with follow-up
questions, provides a mechanism to identify poor performance and encourage staff to make
improvements where services do not live up to the expectations of our patients.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
17
O-Arm
18
The Royal National Orthopaedic Hospital (RNOH) is the first NHS hospital to obtain the
Medtronic O-Arm™ and Stealth Navigation System. This scanner is used intraoperatively to
produce high quality 3D and 2D images which are then used to insert metalwork into the
spine safely, significantly reducing the risk of injury to the spinal cord and nerves.
The advantages are:
• The new scanner gives RNOH surgeons the ability to carry out complex spinal operations
more efficiently and safely and hence significantly improve surgery for patients with
complex spinal deformities and anatomy.
• Being able to perform procedures in this way will ultimately reduce the time needed for
surgery especially for complex procedures – an added benefit being that patients will
require less time under anaesthetic and potentially higher throughput.
• It allows less soft tissue disruption and the use of more minimal access techniques meaning
faster rehabilitation for our patients.
• Less radiation exposure to the surgeon, theatre staff and radiographer.
• It allows for much higher resolution and quality images than existing intra-operative imaging.
Post Anaesthetic Care Unit
The Unit is designed for the post anaesthetic care of children and young adults requiring a
level of critical care. Children and young people admitted to a Post Anaesthetic Care Unit
following a surgical procedure can expect a safe transition from anaesthesia to consciousness.
It has been widely recognised that the special needs of children and young people must be
considered separately.
“Children and young people have special healthcare needs because they are physically and
emotionally different from adults, and need the constant care and support of their parents or
guardians.” (AAGBI)
In addition, The National Service Framework for Children requires that the design and delivery
of hospital services should be centred round the needs of children, young people, and their
families, in a safe, quality assured and suitable manner.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
Remit of the Children’s HDU is to provide specialised post-operative care for children and
young adults requiring level 2 and 3 support
As well as routine management of postoperative care, specialist areas include complex
weaning from ventilators/tracheostomies of patients with neuromuscular disorders and spinal
injury, management of physiological disorders of acute and chronic spinal cord injury and
spinal deformity surgery, and preoperative multidisciplinary assessment of complex needs
patients including sleep study screening.
19
In line with the key characteristics in Comprehensive Critical Care (DOH 2000), and formalised
for children and young people in the PICS standards June 2010 the Paediatric PACU will:
Provide the highest possible standard of care for Level 3 and Level 2 critically ill children and
young people within the unit and support Level 1 patients by integration with the paediatric
wards through the Critical Care Outreach service.
Manage the throughput of children and young people in an effective and efficient way using
evidence based therapeutic measures. The efficiency of the unit will be underpinned by good
quality data collection.
•
•
•
•
•
•
Provide a safe and comfortable environment for the child, young person and their families.
Maintain a planned approach to workforce development.
Continue to remain part of the North West London Critical Care network.
Continue to maintain a relationship with the Children’s Acute Transfer Service.
Care should be centred around the patient rather than the service.
Patients will be seen in a safe, welcoming and clean environment.
Parents and families have been catered for with comfortable seating areas and facilities to
remain at the children’s bedside at all times. Families are encouraged to become involved in
care and discussion around the needs of their child Refurbishment of Private Patients Wards.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
19
Better complaints management
20
The Trust’s Customer Care and PALS Service is easily accessible through both
telephone contact and face to face interaction, providing patients, relatives
and carers with information about the hospital services.
Although the Customer Care and PALS Co-ordinators will offer guidance and
help to patients who feel they need to bring complaints against the Trust,
where possible they will try to resolve any concerns raised at the time
therefore avoiding the need to move to a formal complaint.
information
help
problem
s
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
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When the Trust receives formal complaints the Customer Care and PALS
Co-ordinators will ensure the Trust follows the Principles of Remedy; getting it
right, being customer focussed, being open and accountable, acting fairly
and proportionately, putting things right and seeking continuous
improvement.
This has been implemented as follows:
• Communicating with complainants at an early stage by contacting them by telephone has
ensured that the complainant’s concerns are fully understood so that the relevant issues can
be addressed and resolution for the complainant is fully achieved.
• Face to face meetings are offered at any time during the process to try to resolve issues promptly.
• Keeping the complainant informed of the progress of the investigations.
• Ensuring that investigations are carried out and the information relayed accurately back to
the complainant to ensure we are being open and honest in our responses.
• Responses to complaints will outline where possible what the Trust is doing to rectify or
improve services where there has been a failure.
• The Trust through the Patient’s Experience Improvement Committee reviews the
performance of patient feedback and areas that are highlighted for improvement and these
are monitored through its action plan. The following are examples of where the Trust has
improved service as a result of patient feedback through the Patient’s Experience
Improvement Committee.
• A number of patients had felt that food was served too cold on the wards and now the
hostesses are given further training to ensure that the food is served at the correct temperature
• A complaint regarding the social impact on a patient who was admitted to an adult ward
because he was over the age of 18 years highlighted the need for a booklet to prepare
patients for the transfer from the adolescent to an adult ward.
• A complaint was received from a spinal patient regarding their care due to poor
communication between the Spinal Surgical Unit and the Sarcoma Unit. A co-ordinator is
now in post to manage the patients whose care crosses both services.
• The Patient’s Experience Improvement Committee requested a re-audit of the visiting times
on the SCIC since they had been changed. The feedback highlighted that visiting times
should be extended at weekends, in order to be more flexible for family and friends.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
21
Our priorities for improvement
in 2013/14
Priority 1
22
To continue to ensure patients are safe from infections.
Why?
To further improve health outcomes and the experience our patients receive and eliminate
unnecessary length of stay in hospital.
How we will monitor this
Monthly reporting to wards, directorates and Trust Board.
Priority 2
To continue to reduce the number of incidents of falls in our inpatient areas.
Why?
To minimise the risk of inpatient falls, though use of falls prevention education for patients
and staff.
How we will monitor this
Monthly reporting to wards, directorates and Trust Board.
Priority 3
To ensure all new patients receive as much information as possible while waiting for
appointments.
Why?
To ensure patients understand their treatment options and help them make informed
decisions about their care.
How we will monitor this
Monthly reporting to wards, directorates and Trust Board.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
Priority 4
To increase the number of satisfaction surveys across the Trust to inform service
improvement.
Why?
To inform us of areas that need further improvement and to help us set priorities for our
transformation programme.
How we will monitor this
Monthly reporting to directorates and wards
Priority 5
To improve our admission and discharge processes.
Why?
To improve communication with patients, eliminate unnecessary waiting time and further
improve patients overall experience.
How we will monitor this
Real-time patient feedback and monthly reporting to directorates and wards.
Priority 6
To continue to make advances redeveloping the Trust’s estate to ensure it is safe and
suitable for patients and staff.
Why?
To improve the estate and facilities and further improve patients overall experience and
satisfaction with the services provided.
How we will monitor this
Monthly Clinical Quality Review meetings with Barnet CCG, Real-time patient feedback and
monthly reporting to directorates and Trust Board.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
23
Review of services
24
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
During 2012/2013 the RNOH provided and subcontracted 20 services.
The RNOH has reviewed all the data available on the quality of care in all of these NHS
services.
The income generated by the NHS services reviewed in 2012/2013 represents 100% of the
total income generated from the provision of NHS services by the RNOH for 2012/2013.
The 20 clinical services provided by the RNOH are:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Anaesthesia
Bone Infection Unit
Clinical Neurophysiology
Foot & Ankle
Functional Assessment and Restoration (FARs)
Histopathology and Pathology
Integrated Back Unit
Joint Reconstruction
London Spinal Cord Injury Centre
Orthotics and Prosthetics
Paediatric and Adolescents
Pain Management
Peripheral Nerve Injury Unit
Plastics
Radiology
Rehabilitation and Therapy
Shoulder and Upper Limb
Spinal Surgical Unit
The London Sarcoma Unit
Urology
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
25
Participation in clinical audit
During 2012/13, four national clinical audits and one national confidential enquiry covered
NHS services that the Royal National Orthopaedic Hospital NHS Trust provides.
26
During that period the Royal National Orthopaedic Hospital NHS Trust participated in 100%
(4/4) national clinical audits and 100% (1/1) national confidential enquiry of the national
clinical audits and confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that the Royal National
Orthopaedic Hospital was eligible to participate in during 2012/13 are as follows:
•
•
•
•
•
National Joint Registry: Hip, knee and ankle replacements
National PROMs Programme: Elective surgery
National Comparative Audit of Blood transfusion
National Pain Database
NCEPOD: Cardiac Arrest Procedures Study
The Trust participated within all of the above.
The national clinical audits and national confidential enquiries that the Royal National
Orthopaedic Hospital NHS Trust participated in, and for which data collection was completed
during 2012/13, are listed below alongside the number of cases submitted to each audit or
enquiry as a percentage of the number of registered cases required by the terms of the audit
or enquiry.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
Audit
Number of cases
required by the
audit
Cases submitted
Number
Percentage
National Joint
Registry: Hip, knee
and ankle, elbow &
shoulder
replacements
1138
1103
97%
National
Comparative Audit
of Blood
Transfusion
74
74
100%
National Pain Audit
86
86
100%
*NCEPOD: Cardiac
Arrest procedures
study
n/a
n/a
n/a
*The RNOH took part in the Organisational section of the audit
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
27
Reports from the four national clinical audits were reviewed in 2012/13 and the Royal National
Orthopaedic NHS Trust intends to take the following actions to improve the quality of
healthcare provided:
28
• Training on BCSH guidelines and hospital standard operating procedures, policies and
guidelines to label the tube sample.
• To ensure the Elective Surgery PROMs forms are fully completed for all patients treated
within the RNOH.
• Regular audit of early warning scoring and audit of documentation.
• Induction training for clinical staff and staff competency assessment every 3 years.
The actions/recommendations of (10/10) ‘high’ and ‘medium’ risk clinical audits were reviewed
by the provider in 2012/13 and the Royal National Orthopaedic NHS Trust intends to take the
following actions to improve the quality of healthcare provided, a summary of overall
recommendations are listed below:
• Consent re-audit: to train, raise awareness of the consent procedure/policy for all staff and
amend the consent documentation.
• Deep vein thrombosis diagnosis and early treatment: education of clinical policy on the
intranet for all new starters within the Trust.
• Record keeping re-audit: to establish a medical records committee and continue to conduct
the multidisciplinary record keeping audit to ensure good record keeping within the Trust.
• Unplanned re-admissions to paediatric HDU: to develop referral guidance ensuring all
paediatric patients are appropriately identified for the outreach service within the Trust.
• IRMER x-ray evaluation: to raise awareness of the importance of compliance with national
IRMER standards.
• Anti-microbial use at the RNOH: to develop on-going clinical education for all clinical staff.
• Dementia: ensure all eligible patients aged 75≥ are screened for cognitive impairment on
admission to the Trust.
• VTE Information: to ensure patients receive the VTE information booklet at pre admission is
also available at the patient’s bedside.
• To continue to implement a rolling programme of nursing led audits to highlight accurate
completion of national patient safety issues including; pressure ulcers, nutrition, urinary
catheters and fall assessments.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
Due to the specialist nature of the services that the RNOH provides, the Trust was not eligible
to participate in many of the national audits and national confidential enquires, including
studies from the Centre for Maternal and Child Enquires (CMACE) and the National
Confidential Inquiry (NCI) into Suicide and Homicide by people with mental illness
(NCI/NCISH).
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The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
29
Research
30
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
The number of patients receiving NHS services provided or sub-contracted by
The Royal National Orthopaedic NHS Trust in 2012/2013 that were recruited
during that period to participate in research approved by a research ethics
committee was 126 into NIHR Portfolio studies, and 185 into non-Portfolio
studies.
Illustrative model statement:
The number of patients receiving NHS services provided or sub-contracted by The Royal
National Orthopaedic Hospital NHS Trust in 2012/2013 that were recruited during that period
to participate in research approved by a research ethics committee was 126 into NIHR Portfolio
studies, and 185 into non-Portfolio studies.
Participation in clinical research demonstrates The Royal National Orthopaedic Hospital NHS
Trusts commitment to improving the quality of care we offer and to making our contribution
to wider health improvement. Our clinical staff stay abreast of the latest possible treatment
possibilities and active participation in research leads to successful patient outcomes
The Royal National Orthopaedic Hospital NHS Trust was involved in conducting 60 clinical
research studies of which 28 were initiated in 2012/13 in the neuro- musculoskeletal
specialities.
The improvement in patient health outcomes in The Royal National Orthopaedic NHS Trust
demonstrates that a commitment to clinical research leads to better treatments for patients.
There were over 30 members of clinical staff participating in research approved by a national
research ethics committee at The Royal National Orthopaedic NHS Trust. These staff
participated in research covering neuro-musculoskeletal specialities, across different aspects of
care provided to our patients.
As well, in the last three years, 5 publications have resulted from our involvement in NIHR
research and almost 100 publications link to other research, which shows our commitment to
transparency and desire to improve patient outcomes and experience across the NHS.
Our engagement with clinical research also demonstrates The Royal National Orthopaedic NHS
Trust commitment to testing the latest medical treatments and techniques.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
31
Goals agreed with
commissioners
32
Commissioning for Quality and Innovation (CQUIN) is a payment framework,
which allows commissioners to agree payments to hospitals based on agreed
improvement work.
Through discussions with our commissioners, we agreed a number of improvement goals for
2012/13, which reflect areas of improvement interest within London, locally and nationally.
The amount of income in 2012/13 agreed between the RNOH and our host commissioner
NHS North Central London based on quality improvement and innovation goals was
£287,231.
A high level summary of the CQUIN measures for 2012/13 is shown in the following table:
Performance indicator
Value
VTE prevention
£40,218.50
Patient experience
£40,218.50
Dementia screening
£36,771.20
Patient Safety Thermometer
£40,218.50
Vulnerable patients
£22,982.00
Increasing the stop smoking offer in health services
£40,218.50
Enhanced recovery programme
£40,218.50
Complete and accurate recording of cancer staging data
£22,982.00
Total
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
£287,275.00
Through discussions with NHS North Central and East London we have agreed the following
Commissioning for Quality and Innovation (CQUIN) for 2013/14 as follows:
Performance indicator
Value
VTE prevention
£35,598.61
Patient experience - Friends and family test
£35,598.61
Patient Safety Thermometer
£35,598.61
Dementia screening of over 75s.
£35,598.61
Increasing the stop smoking offer in health services
Surgical site infection screening (SSIS)
Total
£142,394.45
£71,197.23
£355.986.00
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
33
What others say about the Royal
National Orthopaedic Hospital
Quality Index Report (Assessment of NHS quality in England by MHP Health)
34
The Quality Index report, published by MHP Health in March 2013, was the first ever overall
assessment of NHS hospital quality in England based on what matters most to people.
Almost a quarter (23%) of respondents said that the factor they considered most important
when deciding which hospital to have an operation in was the number of patients who said
that they had a good experience of care at the hospital. One fifth of respondents (20%)
placed greatest importance on how long they would have to wait for an operation.
As part of the ‘quality at a glance’ report 146 Trusts were assessed, with the RNOH ranked as
the 7th highest performing Trust.
Care Quality Commission
The Care Quality Commission (CQC) is the organisation which regulates and inspects health
and social care services in England. All NHS hospitals are required to be registered with the
CQC in order to provide services and are required to maintain specified ‘essential standards’ in
order to retain their registration.
As part of its role, the CQC is required to monitor the quality of services provided across the
NHS and to take action where standards fall short of the essential standards. Their assessment
of quality is based on a range of diverse sources of external information about each Trust,
which is regularly updated and reviewed.
This is in addition to their own observations during periodic, planned and unannounced
inspections. If an issue raises concern during the data review process
or from other sources of information, the CQC may undertake an unplanned, responsive
inspection.
For both its locations, the RNOH is fully registered with the CQC without conditions.
No enforcement action has been taken against the RNOH during 2012/13.
The CQC inspected the RNOH in January 2013 and assessed that the Trust was meeting all
standards except Outcome 10 – Safety and suitability of premises.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
Standards of treating people with respect and involving them in
their care
3
Standards of providing care, treatment and support, which meets
people's needs
3
Standards of caring for people safely and protecting them from
harm
7
Standards of staffing
3
Standards of management
3
Summary of the inspection
The inspection team included a pharmacist inspector. They inspected two children's wards, the
pharmacy, a post operation ward and three inpatient wards.
They spoke with 19 people who use the service, four visitors and 56 members of staff. Most
patients were satisfied with their care and treatment. They told them that these had been
explained and that they were involved in their treatment. They said that their privacy and
dignity was maintained.
This was confirmed by the staff they spoke with and the records they viewed. Most patients
told them that they had access to their own medication and staff supported them with this
when required. The hospital ensured medication was administered appropriately, however
they found it was not always stored correctly. Patients told them they were generally happy
with the environment of the hospital but some commented that the premises were
"restrictive" and "in need of repair".
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
35
Work completed regarding the safety and suitability of premises (Outcome 10) since
the visit by the Care Quality Commission in January 2013.
36
• Repairs to the shower room in the Spinal Cord Injuries Centre.
• Surveyed the general wards and put in place a redecoration programme for 2013/14. The
priority areas include Angus MacKinnon Ward and Alan Bray (ITU).
• Increased routine maintenance frequencies.
• Upgraded medicine storage in all ward areas which are fully compliant.
What the Trust is planning to do regarding the safety and suitability of premises
(Outcome 10).
• The Trust fully acknowledges the difficulties the slope corridor creates for patients. This
situation is being addressed by the replacement of these wards through our approval of the
new PFI building. The Trust is on target for construction to commence in 2014, with the
new facilities open in 2016. This will enable the slope corridor to be demolished.
• Increase our routine monitoring estates issues in relation to wards and other patient areas.
• The Trust has a carpet replacement programme with priority areas agreed with Infection
Control. Works to the wards is included in the Trust’s Capital programme for 2013/14.
• The Trust is addressing the drainage problems as part of its infrastructure enabling for its
new PFI Ward Block building which is in progress.
• The Trust acknowledges that the space at bedsides is insufficient for equipment and patient
belongings. General storage is also limited. This situation is being addressed by replacement
of wards through our approval of the new PFI building. The new facilities will have
compliant bed spaces and sufficient adjacent storage.
• A Business Case is being developed to automate the Pharmacy function by the use of
Robots. This will also address the security within the main Pharmacy department.
• The majority of wards have had their heating systems upgraded. Some areas have
antiquated heating control systems which results in fluctuations in temperature within the
work environment. This will be resolved through the replacement of the building stock,
upgrade to existing systems and the disposal of land and buildings as part of our master
plan for site development.
• The Trust acknowledges that in some clinical areas the environment is unsuitable for
The CQC produces a monthly Quality and Risk Profile (QRP)) that provides the RNOH with a
risk estimate for each outcome in the essential standards of quality and safety.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
The Quality and Risk Profile (QRP) is a tool that gathers all that is known about the Trust in one
place. The information is sourced and analysed from a range of sources that include:
•
•
•
•
Other regulatory bodies – for example NHS Litigation Authority
Routine data collections – for example patient surveys
National clinical audit datasets
Information from people using the services for example NHS Choices
These risk estimates are produced using a statistical model that aggregates individual items of
information and are displayed as dials.modern healthcare. This will be resolved with the
building of the new hospital.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
37
The risk estimate in March 2013 for each of the underlying outcomes in the essential
standards of quality and safety was as follows:
38
SECTION 1: Involvement & Information
Outcome 1 (R17)
Involving people who use services
Outcome 2 (R18)
Consent to care and treatment
L
L
High Green
No
Information
H
H
SECTION 2: Personalised Care, Treatment and Support
Outcome 4 (R9)
Care and welfare of people who use services
Outcome 5 (R14)
Meeting Nutritional Needs
Outcome 6 (R24)
Cooperating with other providers
L
L
L
High Green
Low Neutral
High Green
H
H
H
SECTION 3: Safeguarding and Safety
Outcome 7 (R11)
Safeguarding people who use services from
abuse
Outcome 8 (R12)
Cleanliness and infection control
Outcome 9 (R13)
Management of medicines
Outcome 10 (R15)
Safety and suitability of premises
Outcome 11 (R16)
Safety, availability and suitability of equipment
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
L
L
L
High Green
High Green
High Green
H
H
H
See page 36 for details
L
High Green
H
SECTION 4: Suitability of staffing
Outcome 12 (R21)
Requirements relating to workers
Outcome 13 (R22)
Staffing
Outcome 14 (R23)
Supporting Staff
L
L
L
Low Neutral
High Green
Low Neutral
H
H
H
SECTION 5: Quality & Management
Outcome 16 (R10
Assessing and monitoring the quality of
service provision
Outcome 17 (R19)
Complaints
Outcome 21 (R20)
Records
L
L
L
High Green
Low Neutral
High Green
H
H
H
Note: The risk profile published in March did not reflect the outcome of the CQC visit in
January 2013.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
39
Redevelopment of the
Stanmore site
40
In May 2012 the Trust received approval of its Outline Business Case
Addendum from the Department of Health to proceed to the competitive
dialogue stage of the redevelopment of the Stanmore site. This phase of the
redevelopment will focus on the provision of a brand new suite of wards and
a state-of-the art Imaging Department - designed to improve patients'
experience at the Trust.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
41
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
Specialist OrthopaedicAlliance
42
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
The Royal National Orthopaedic Hospital NHS Trust is a founding member of
the Specialist Orthopaedic Alliance.
The vision of the Specialist Orthopaedic Alliance is to be a primary source of support and
expertise to the NHS and elsewhere on the provision of orthopaedic services. This will promote
the sharing of best practice, the delivery of high quality outcomes for patients, better value for
money through productivity and long term cost savings with better outcomes and therefore
lower cost to the NHS. At its most basic this can be described as supporting the NHS ensure
that its policies and systems promote appropriate orthopaedic referrals getting to the right
experts, in the appropriate setting, at the right time who, by getting it right first time, reduce
complications, and use evidence based treatments. Coupled with appropriate innovation and
different modes of working, this approach will improve the quality of care for patients.
This will deliver greater patient satisfaction and enhanced outcomes. It will also produce
significant annual savings to the NHS and reduce waiting times.
The Specialist Orthopaedic Alliance will facilitate collaboration within the NHS and outside to
support the delivery of its vision. The SOA will interface with MPs, Ministers, Health Select
Committee, the NCB, specialist commissioners, and partner bodies such as the British
Orthopaedic Association, Royal College of Surgeons, and the British Orthopaedic Directors
Society. This will include supplying information, reporting, commentary and other support and
expertise on national or local policy initiatives that impact the delivery of orthopaedic services.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
43
How we ensure a legacy of
continuous innovation and quality
improvement
Infusion Suite
44
In June 2012 the Jubilee Rehabilitation Centre opened its doors after a closure of 4 months
due to a flood. In the refurbishment a decision was taken to invest in an infusion suite with
the main focus of being able to provide an enhanced clinical area to provide patients of the
metabolic services with their yearly drug therapy.
Since we opened we have increased the number of clinic days and now run a nurse led clinic
on a Tuesday, this has allowed the doctor to continue their training and gain clinical
experience of the metabolic clinic under the guidance of Dr Keen.
Overall the patients that have been through the service previously have commented on how
impressed they are with the new facilities as they feel that it is a more professional clinical
area. We are in the process of collecting data on patient satisfaction of this new service.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
Hotel Based Rehabilitation and Pain Management Programme
The Royal National Orthopaedic NHS Trust offers hotel based residential programmes for
adults with long-term chronic neuromuscular and musculoskeletal conditions. These
programmes offer a mix of individual and group sessions with input from health psychology,
nursing, occupational therapy, physiotherapy and medical specialties including rheumatology,
rehabilitation medicine and chronic pain management.
The hotel provides a better environment for patients as:
• It de-medicalises the programme and provides
a normal environment which is in keeping with
the ethos of our programmes (teaching people to
take responsibility for managing their long term
condition).
• Patients can access hotel facilities (swimming pool,
sauna) as part of their rehabilitation
• Patient’s value having a private room in the hotel
which allows them to have some privacy between
sessions. It also provides a quiet environment in which they can get a good night’s
sleep (sometimes impossible on the ward) and this has a positive effect in their ability to
engage in rehab.
Outpatients Improvement
During 2012/13 the Outpatients Department at Stanmore was improved creating a new
environment for patients to relax and feel welcome in when attending their appointment.
Workshops were held to ensure our patients and staff views were considered in the redesign
and refurbishment of the department.
Work will continue in 2013/14 to further expand the department creating additional clinic
capacity to ensure we meet the increase in demand for services provided by the RNOH.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
45
Data quality
The Royal National Orthopaedic Hospital NHS Trust has undertaken the following
actions to improve data quality:
46
• A Data Quality Assurance paper was commissioned by the Trust Board this paper
incorporated a section identifying the data quality assurance processes attached to all
existing data quality reports and regular data submissions. As further reports are developed
these will be incorporated.
• The Data Quality Group has met regularly throughout 2012/2013.
• The work embarked on previously to identify data quality requirements has progressed with
the identification of a set of data quality measures. These measures have been incorporated
within a monthly DQ RAG Status report which is monitored and reviewed at the DQ
meetings. The report with accompanying commentary is reported through the Trust
Committee structure by submission to the IM&T Committee.
• The Data Quality dashboard continues to be enhanced with additional reports
incorporating additional key data items.
The Royal National Orthopaedic Hospital NHS Trust submitted records during
2012/2013 to the Secondary Uses service for inclusion in the Hospital Episode
Statistics which are included in the latest published data. The percentage of records
in the published data which included the patient’s valid NHS number was:
98.8% for admitted care
99.1% for outpatient care
The percentage of records in the published data which included the patient’s valid General
Medical Practice Code was:
100% for admitted care
100% for outpatient care
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
Information Governance
Information Governance assesses the way organisations ‘process’ or handles information. It
covers personal information (i.e. that relates to patients/service users and employees) and
corporate information (e.g. financial records).
IG provides a way for employees to deal consistently with the many different rules about how
information is handled, including those set out in:
•
•
•
•
•
•
•
•
•
The Data Protection Act 1998
The common law duty of confidentiality
The Confidentiality NHS Code of Practice
The NHS Care Record Guarantee for England
The Social Care Record Guarantee for England
The international information security standard: ISO/IEC 27002: 2005
The Information Security NHS Code of Practice
The Records Management NHS Code of Practice
The Freedom of Information Act 2000
The Royal National Orthopaedic Hospital NHS Trust Information Governance Assessment
Report score for 2012/13 was 72% and was graded green.
The last Payment by Results Clinical Coding Audit by the Audit Commission placed RNOH in
the top quartile of trusts for coding accuracy. An internal Clinical Coding audit during the
reporting period has shown a marked improvement over previous years with over 95%
Clinical Coding accuracy.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
47
NHS Outcomes Framework –
Overarching indicators
48
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
Summary Hospital Level Mortality
(SHMI)
A summary hospital-level mortality
indicator (SHMI), value, banding and
supporting palliative care data was not
published for specialist Trusts for 2012/13.
There were five deaths at the RNOH in
2012/13, (seven in 2011/12, three in
2010/2011 and six in 2009/10).
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
49
Patient reported outcome measures (PROMs).
The Royal National Orthopaedic Hospital NHS Trust considers that the Patient Reported
Outcomes Measures (PROMs) are as described for the following reasons:
50
• We introduced PROMs in 2010 for patients who had hip and knee replacement surgery.
These measure a patient’s health gain after surgery. The information is gathered from the
patient who completes a questionnaire before and after surgery. The responses are
analysed by an independent company and benchmarked against other Trusts.
The Royal National Orthopaedic Hospital NHS Trust has taken the following actions to improve
the health gain of patient’s having hip and knee surgery to improve the quality of its services by:
• Reviewed the data with the Department of health to compare case mix and complexity
against other specialist orthopaedic trusts.
• Implemented an enhanced recovery programme for patients having hip or knee replacements.
The Royal National Orthopaedic Hospital NHS Trust intends to take the following actions to improve
the health gain of patient’s having hip and knee surgery to improve the quality of its services by:
• Investing in an electronic outcomes data capture system (POD).
• Continuing to review and benchmark PROMs data against other specialist orthopaedic trusts.
NHS
Outcomes
Framework
Domain
Indicator
Domain 3:
helping
people to
recover from
episodes of
ill health or
following
injury
Patient reported
outcome scores
(PROMs) of total
health gain as
assessed by
patients for
elective surgical
procedures:
2010/
2011
2011/
2012
2012/
2013
Provisional
Provisional
National
average
in 2012/
2013
Highest
average
other
Trusts
2012/13
Lowest
average
other
Trusts
2012/13
Average
health
gain
where
full
health
=1
Hip replacement
0.340
0.352
0.380
0.437
0.690
0.155
Knee replacement
0.215
0.176
0.216
0.312
0.527
0.031
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
Emergency readmissions to hospital within 28 days of discharge
The Royal National Orthopaedic Hospital NHS Trust admitted 15129 NHS patients in 2012/13
of these 53 (0.35%) were emergency readmissions within 28 days of discharge.
The Royal National Orthopaedic Hospital NHS Trust considers that the percentage of
emergency re-admissions within 28 days of discharge from hospital is as described for the
following reasons:
• Every time a patient is discharged and readmitted to hospital, staff code the episode of
care. The Information team continually monitors and audits data quality locally and we
participate in external audit which enables the Trust to benchmark its performance against
other Trusts.
The Royal National Orthopaedic Hospital NHS Trust intends to take the following actions to
reduce readmissions to improve the quality of its services by:
• We will work with commissioners to put in routine monitoring systems to monitor those
patients discharged from the Royal National Orthopaedic Hospital NHS Trust and
readmitted to other hospitals to ensure accurate readmission rates and appropriate clinical
review of any readmissions within 28 days.
NHS
Outcomes
Framework
Domain
Indicator
2010/
2011
2011/
2012
2012/
2013
National
average
in 2012/
2013
Highest
average
other
Trusts
2012/13
Lowest
average
other
Trusts
2012/13
Domain 3:
helping
people to
recover from
episodes of
ill health or
following
injury
Percentage
of emergency
readmissions
within 28 days
of discharge
from hospital of
patients aged:
0 to 14
N/A
N/A
0.29%*
4%
Not
available
Not
available
15 or over
N/A
N/A
0.05%*
6.3%
* This data does not include patients discharged from the RNOH and readmitted to other hospitals.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
51
Responsiveness to the personal needs of patients
The Royal National Orthopaedic Hospital NHS Trust considers that the mean score of
responsiveness to inpatient personal needs is as described for the following reasons:
52
• Each year the Trust participates in the National Inpatient Survey. A random sample of 850
patients are sent a nationally agreed questionnaire and the results are analysed
independently by The Patient Survey Co-ordination Centre.
The Royal National Orthopaedic Hospital NHS Trust has taken the following actions to improve
responsiveness to inpatient personal needs and improve the quality of its services by:
• Training on Customer Care for all nurses
• Introduced of card with admission and discharge information for patients.
• Displayed posters on wards displaying the management team saying who to contact if you
need help and advice.
The Royal National Orthopaedic Hospital NHS Trust intends to take the following actions to
improve responsiveness to inpatient personal needs and improve the quality of its services by:
•
•
•
•
ACUITY tool being introduced.
Introduction of Intentional Rounding in all ward areas.
Ensure TTA’s are prescribed well in advance of discharge.
Include a question on cleanliness in the Real Time Patient Feedback
NHS
Outcomes
Framework
Domain
Indicator
Domain 4:
ensuring
that people
have a
positive
experience
of care
Responsiveness
to inpatients’
personal needs
(mean score)
2010/
2011
2011/
2012
2012/
2013
National
average
in 2012/
2013
Highest
average
other
Trusts
2012/13
Lowest
average
other
Trusts
2012/13
N/A
72.5
73.9
71.1
85.6
56.6
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
Staff who would recommend the hospital to friends and family needing care
The Royal National Orthopaedic Hospital NHS Trust considers that the percentage of staff who
would recommend the hospital to friends and family needing care is as described for the
following reasons:
• Each year the Trust participates in the National Staff Survey. A random sample of 800 staff
are sent a nationally agreed questionnaire by an independent company. The results are
analysed by the Staff Survey Co-ordination Centre.
• The Trust finished in the top 10 of hospital trusts nationally, it came 9th out of 161 hospital
Trusts.
NHS
Outcomes
Framework
Domain
Indicator
Domain 4:
ensuring
that people
have a
positive
experience
of care
Percentage of
staff who would
recommend the
hospital to
friends or family
needing care
2010/
2011
2011/
2012
2012/
2013
National
average
in 2012/
2013
Highest
average
other
Trusts
2012/13
Lowest
average
other
Trusts
2012/13
78.8
78.8
89
60
Not
available
Not
available
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
53
54
Venous thromboembolism (VTE).
The Royal National Orthopaedic Hospital NHS Trust considers that the percentage of patients
admitted to hospital and who were risk assessed for venous thromboembolism (blood clots) is
as described for the following reasons:
• Patients are assessed on the wards and data is captured electronically and analysed by a
senior nurse linked to the Thrombosis Committee.
The Royal National Orthopaedic Hospital NHS Trust has taken the following actions to improve
the percentage of patients admitted to hospital who were risk assessed for venous
thromboembolism to improve the quality of its services by:
• On-going education of staff, patients and raising awareness with members of the public.
• Feedback of the monthly audit results to the wards and clinical leads to drive improvement.
• In-depth analysis of patients who develop a thrombosis in hospital to learn and improve.
NHS
Outcomes
Framework
Domain
Indicator
Domain 5:
treating and
caring for
people in a
safe
environment
and protecting
them from
avoidable
harm
Percentage of
admitted
patients risk
assessed for
Venous
Thromboembolism
2010/
2011
2011/
2012
2012/
2013
National
average
in 2012/
2013
Highest
average
other
Trusts
2012/13
Lowest
average
other
Trusts
2012/13
68.4%*
93.7%
96.7%
94.2%
100%
84.6%
to
31/12/12
to
31/12/12
to
31/12/12
to
31/12/12
* Data for 2010/11 November 2010 – March 2011 (5 months only)
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
C. difficile infection
The Royal National Orthopaedic Hospital NHS Trust considers that the rate per 100,000 bed
days of cases of C.difficile infection are as described for the following reasons:
• The Trust complies with Department of Health guidance against which we report positive
cases of C difficile. We submitted our data to the Health Protection Agency and are
benchmarked nationally against other Trusts. C.difficile data is subject to external audit for
assurance purposes.
The Royal National Orthopaedic Hospital NHS Trust has taken the following actions to reduce the
rate per 100,000 bed days of cases of C.difficile infection to improve the quality of its services by:
• Maintaining and monitoring good infection control practice including hand hygiene and
taking action to improve.
• Maintaining and monitoring standards of cleanliness and taking actions to improve.
• Designated ward rounds to ensure best practice in antibiotic prescribing.
• Root cause analysis of patients who develop C difficile in hospital to learn and improve.
The Royal National Orthopaedic Hospital NHS Trust intends to take the following actions to reduce
the rate per 100,000 bed days of cases of C.difficile infection to improve the quality of its services by:
• Continued vigilance through the above actions
NHS
Outcomes
Framework
Domain
Indicator
Domain 5:
treating and
caring for
people in a
safe
environment
and protecting
them from
avoidable
harm
*Rate of C.
difficile per
100,000
bed days
2010/
2011
2011/
2012
2012/
2013
National
average
in 2012/
2013
Highest
average
other
Trusts
2012/13
Lowest
average
other
Trusts
2012/13
5.9
7.9
18.6
21.8
51.6
1.9
* Rate calculated on Trust apportioned cases only of patients aged 2 years and over.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
55
Comparison of the number of C. difficile infections reported by the Trust 2010/11 –
2012/13
56
3.5
2010/2011
2011/2012
3
2012/2013
2.5
2
1.5
1
0.5
0
April
May
June
July
August
September
October
November
December
January
February
March
Patient safety incidents
The Royal National Orthopaedic Hospital NHS Trust considers that the rate of patient safety
incidents reported and the number and percentage of such incidents that resulted in severe
harm or death are as described for the following reasons:
• The Trust actively promotes an open and fair culture that encourages the honest and timely
reporting of adverse events and near misses to ensure learning and improvement action
are taken.
• The Trust submits patient safety incident data to the National Reporting Learning System.
We are ranked against other Trusts in respect of the rate of reporting and category of harm.
• Each incident is classified by risk from low to high. Trends are then identified within each
category. The majority of incidents are graded as acceptable risks, either due to the rarity of
their occurrence, the minimal harm experienced or the control measures already in place.
• Serious incidents are investigated by a nominated multidisciplinary team using the root
cause analysis process and action plans are monitored via the Clinical Quality Governance
Committee and our quality review meeting with NHS England (North Central & East London).
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
The Royal National Orthopaedic Hospital NHS Trust has taken the following actions to reduce
the rate of patient safety incidents and the number and percentage of such incidents that have
resulted in severe harm or death to improve the quality of its services by:
• Investigating clinical incidents and serious incidents and sharing the lessons learnt across the
Trust and ensured recommendations are implemented through the Directorate quality
performance meetings.
The Royal National Orthopaedic Hospital NHS Trust intends to take the following actions to
reduce the rate of patient safety incidents and the number and percentage of such incidents
that resulted in severe harm or death to improve the quality of its services by:
• Continuing to actively promote reporting, investigation of clinical incidents and serious
incidents, sharing learning across the Trust and with our commissioners to ensure
improvement in the Trust and outside the organisation.
NHS
Outcomes
Framework
Domain
Indicator
Domain 5:
treating and
caring for
people in a
safe
environment
and protecting
them from
avoidable
harm
2010/
2011
2011/
2012
2012/
2013
Rate of patient
safety incidents
reported.
4.0
4.8
5.6
The percentage
of such incidents
that resulted in
severe harm or
death
2.2%
0.6%
0.7%
National
average
in 2012/
2013
5.8
incidents
per 100
admissions
(to 7/9/2012)*
Highest
average
other
Trusts
2012/13
Lowest
average
other
Trusts
2012/13
Not
available
Not
available
0.5%
*The number of incidents per 100 admissions is taken from the National Reporting Learning
System (NRLS) report. This shows the latest actual figures reported nationally for the Trust
which are always 6 months in arrears.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
57
58
The latest patient safety incident report
(Published by the NHS Commissioning Board March 2013)
The Royal National Orthopaedic Hospital NHS Trust reported incidents to the National
Reporting and Learning System (NRLS) in 6 out of the 6 months between
April 2012 and September 2012.
Fifty per cent of all incidents were submitted to the NRLS more than 30 days after the incident
occurred. In your organisation, 50% of incidents were submitted more than 11 days after the
incident occurred.
What type of incidents are reported in your oganisation?
Top 10 incident types
Medication
9.3%
8.7%
15%
11.2%
Treatment, procedure
10.6%
Patient accident
Documentation (including records,
identification)
Clinical assessment
34.1%
8.8%
3.4%
7.6%
4.8%
Implementation of care and ongoing
monitoring/review
6.5%
6.6%
Access, admission, transfer,
discharge
6.3%
6.9%
Consent, communication,
confidentiality
5.2%
6.4%
Medial device/equipment
5.1%
4.6%
Infrastructure (including staffing,
facilities, environment)
3.4%
4.3%
All other categories
0%
9.3%
8.7%
20%
Your organisation
All acute specialist organisations
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
40%
60%
Percent of incidents
80%
100%
100
Your organisation
Percent of incidents occuring
90
80
70
All acute specialist
organisations
72%
60
50
40
43.9%
34.3%
30
22.7%
20
10
0
21.1%
4.9%
None
Low
None
Low
192
150
Moderate
0.5%
0.4%
0.2%
0.1%
Severe
Death
Moderate
Severe
Death
92
2
1
Degree of harm
Your
figures:
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
59
Review of quality performance
Patient experience
Number of written patient complaints received
60
25
2010/2011
2011/2012
20
2012/2013
15
10
5
0
April
May
June
July
August
September
October
November
December
January
February
March
134 complaints were received in 2012/13; this was 14 more than in 2011/12.
Number of Patient Advice and Liaison Service enquiries received
160
2010/2011
140
2011/2012
120
2012/2013
100
80
60
40
20
0
April
May
June
July
August
September
October
November
December
January
February
March
The Patient Advice and Liaison Service dealt with 1221 enquiries in 2012/13.212 more than
the 1009 in 2011/12.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
Patient Safety
Clinical Incidents reported
Each incident is classified by risk from low to high. Trends are then identified within each
category. The majority of incidents are graded as acceptable risks, either due to the rarity of
their occurrence, the minimal harm experienced or the control measures already in place.
Serious incidents are investigated by a nominated multidisciplinary team using the root cause
analysis process and action plans are monitored via the Clinical Quality Governance
Committee and our quality review meeting with NHS North Central & East London.
25
2010/2011
2011/2012
20
2012/2013
15
10
5
0
April
May
June
July
August
September
October
November
December
January
February
March
1660 clinical incidents were reported in 2012/13. This was 180 less than the 1840 reported in
2011/2.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
61
Pressure Sores
62
10
2010/2011
9
2011/2012
8
2012/2013
7
6
5
4
3
2
1
0
April
May
June
July
August
September
October
November
December
January
February
March
In 2012/13, 16 pressure sores were acquired by RNOH patients while under our care.
We are pleased that the severity and incidence of sores has decreased from previous years (28
in 2011/12, 31 in 2010/11, 49 in 2009/10).
The RNOH recognises, however, that we have further work to do to reach our target of zero
sores. Our matrons continue to work closely with the tissue viability service to further reduce
the incidence of pressure sores.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
Medication Errors
35
2010/2011
2011/2012
30
2012/2013
25
20
15
10
5
0
April
May
June
July
August
September
October
November
December
January
February
March
There were 153 medication errors reported in 2012/13, this was 26 less than in 2011/12.
Nutritional assessment within 48 hours of admission
10
2010/2011
9
2011/2012
8
2012/2013
7
6
5
4
3
2
1
0
April
May
June
July
August
September
October
November
December
January
February
March
A greater number of patients benefited from a nutritional assessment within 48 hours of
admission in 2012/13 as shown in the graph above.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
63
Infection control
64
In line with the Health and Social Care Act 2008, the RNOH has an
appropriately constituted Infection Prevention and Control Team to provide
expertise, knowledge and support to encourage and enable members of staff
working across the trust to enhance and sustain their performance in ensuring
patient safety by preventing avoidable infections.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
65
Meticilin Resistant Staphylococcus aureus Bacteraemia
The Trust has reported zero Meticilin Resistant Staphylococcus aureus (MRSA) blood stream
infections since 2009 which remains lower than London and England. MRSA bacteraemia
results remain zero as a result of the continued combined effort of all clinical and non-clinical
staff at RNOH. Such efforts include;
65
•
•
•
•
Updated MRSA policy
Staff training and education
Robust MRSA screening protocol for all patients being admitted to RNOH
Audit programme that includes checking the MRSA status of patients booked for theatre
and feedback of results to staff.
• MRSA IT flagging system to identify patients with previous MRSA
• Close liaison between bed management and infection control
• MRSA screening included on the admissions checklist
Meticilin Sensitive Staphylococcus aureus bacteraemias
The Trust reported two Meticilin Sensitive Staphylococcus aureus bacteraemias for the year
2012-13 compared to one bacteraemia in 2011-12 and zero in 2010-11.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
65
Clostridium difficile toxin
66
The trust reported eleven Clostridium difficile toxin (CDT) positive cases in 2012-13 compared
to four reported for the same period last year however the reporting requirements changed in
April 2012 and a greatly expanded infection service at RNOH has led to increased awareness
and testing. Comparisons are therefore difficult and reporting differences need to be taken
into account.
Combined efforts to reduce CDT positive cases in the trust include;
•
•
•
•
•
•
•
•
•
Prudent antimicrobial prescribing
Early isolation of cases
Improved documentation in medical notes
Checklist for actions
Enhanced environmental cleaning using chlorine based disinfectant
Appropriate infection prevention and control precautions at point of contact
Hand hygiene, particularly washing with soap and water
Use of personal protective equipment
Sign on the patients door indicating precautions required.
Escherichia coli bacteraemia
RNOH reported three E.coli bacteraemia in 2011/12 and three in 2012-13
Surgical Site Surveillance
From April 2011 the Trust surveillance officer has identified all patients undergoing hip, knee
and spinal surgery and coordinated a postal and telephone survey to identify signs of infection
at 30 days post operatively.
The SSI’s that have been confirmed for the period January 2012 – December 2012 for total hip
replacements, total knee replacements and spinal surgery are shown in the table 1,
percentages are shown in figure 1.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
Table 1. RNOH Number of operations, infections and percentages – Total Hip Replacements,
Total Knee Replacements and spinal Surgery 2012
Total Hip
Replacements
Total Knee
Replacements
Spinal
Surgery
Month
2012
No.
Ops
No.
Infections
%
No.
Ops
No.
Infections
%
No.
Ops
No.
Infections
%
January
28
0
0%
28
0
0%
67
1
1.49%
February
33
0
0%
31
0
0%
70
0
0%
March
55
0
0%
41
1
2.40%
90
1
1.10%
April
36
0
0%
29
0
0%
66
0
0%
May
41
0
0%
39
0
0%
79
2
2.50%
June
28
0
0%
35
0
0%
85
2
2.30%
July
37
0
0%
33
2
6%
120
0
0%
August
22
0
0%
33
0
0%
73
3
4.10%
September
24
0
0%
35
1
2.8%
103
1
0.90%
October
34
0
0%
41
0
0%
105
1
0.90%
November
28
0
0%
46
1
2.1%
81
2
2.40%
December
30
0
0%
34
0
0%
91
1
1%
7%
Total knee
replacements
6%
Spinal
surgery
5%
4%
3%
2%
1%
0%
January
February
March
April
May
June
July
August
September
October
November
December
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
67
Management and leadership
68
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
The RNOH continues to maintain its reputation for recruiting and developing high quality,
specialist staff.
To support this, the RNOH’s organisation development strategy has been agreed by the
organisation and an implementation plan is currently under development. The strategy is a
planned and systematic approach to enabling sustained organisational performance through
the involvement and engagement of RNOH staff. One example of the strategy that is already
in practice is the introduction of the HR Business Partner service at the beginning of 2013.
Staff Turnover
Staff turnover was 13.32%. The Trust is committed to reducing this by at least 1% in the
coming year.
Staff Sickness
The RNOH aimed to reduce its staff sickness rate to 3%. Despite failing to achieve this with an
actual rate of 3.52%, the RNOH continues to be among the Trusts with the lowest sickness
rates when benchmarked against other specialist orthopaedic Trusts and Trusts in London. The
Trust will be seeking to meet the 3% target in the coming year through a targeted case
management approach which is already resulting in significant reductions in specific areas.
Listening to our staff
The annual NHS staff survey provides a wealth of information about staff views on working at
the Trust. The Trust was rated one of the top 10 most trusted hospitals according to the 2012
NHS staff survey with 89% of staff stating that they would recommend the treatment
available at the hospital to their friends and family. This result is encouraging and testament to
the high quality care provided by our staff. Whilst seeing improvements in areas such as
fairness and effectiveness of incident reporting procedures and an increase in training received
by staff (including equality and diversity training), the Trust remains concerned about the level
of work-related stress and bullying and harassment experienced by staff. Staff survey feedback
sessions and the development of directorate-level action plans aim to effect improvements in
these areas in 2013/14.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
69
Our Quality Ambitions
In 2013/14 the Trust will be launching its Quality Strategy and Quality Ambitions.
70
Our Quality Ambitions
• To deliver safe and appropriate evidence based care to all our patients, to ensure the
best possible clinical outcomes and overall patient experience. The partnerships
between those delivering services and patients and carers will respect individual needs
and values and demonstrate compassion continuity, clear communication and shared
decision-making.
• A zero harm culture for the healthcare patients receive, and that they are cared for in
an appropriate, clean and safe environment at all times.
• The most appropriate treatments, interventions, support and services will be provided
at the right time to everyone who will benefit, with no wasteful or harmful variation.
Quality Outcome Measures
Our Quality Goals
• Hospital Standardised Mortality Rates
• Patient reported outcome measures
(PROMs)
• Emergency readmissions within
28 days of discharge
• Responsiveness to patient needs
• Patient experience of access to services
• Staff experience
• Staff attendance
• Patient experience (Friends & Family test)
• Healthcare Associated Infections
• Reported patient safety incidents
• Staff views on standards of care
• Pressure ulcers
• Local Key performance indicators (KPIs)
• Staff, patients and public are
confident that the Royal National
Orthopaedic Hospital NHS Trust is
reliably and consistently safe, effective
and responsive to their needs.
• Everyone working at the Royal
National Orthopaedic Hospital NHS
Trust is confident that they will
supported to do what they came in
to the NHS to do, and that they are
valued for doing that.
• To have a shared pride in the Royal
National Orthopaedic Hospital NHS
Trust and a recognition that it is
amongst the best providers of
healthcare in the world.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
Publishing and involving
stakeholders in our
Quality Account
Our Quality Account is published on NHS Choices and can be downloaded from our own
website at www.rnoh.nhs.uk
71
Your feedback is important to us
If you would like to comment on this Quality Account or make suggestions about what it
could contain next year, then we would like to hear from you. We also welcome all feedback
from the people who use our services and appreciate any suggestions for improvement.
• by email to stuart.coalwood@rnoh.nhs.uk
• or by post to:
Stuart Coalwood
Assistant Director of External Compliance and Quality Assurance
Royal National Orthopaedic Hospital NHS Trust
Brockley Hill
Stanmore
Middlesex
HA7 4LP
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
Statement from NHS Barnet
Clinical Commissioning Group
72
Clinical Commissioning Groups (CCG) in north central London are responsible for the
commissioning of health services located in Barnet, Camden, Enfield, Haringey and Islington.
Barnet CCG is also responsible for commissioning health services from The Royal National
Orthopaedic Hospital in Stanmore, Middlesex.
Barnet CCG supported by North East London Commissioning Support Unit has reviewed and
is pleased to assure the 2012/13 Quality Account for The Royal National Orthopaedic Hospital.
The Quality Account was discussed at the June 2013 Clinical Quality Review Meeting (CQRM)
and the Quality Account underwent further amendments based on feedback.
The accounts provide a comprehensive summary of the work done by the Trust in 2012/13 to
enhance and improve their services to patients. There are a number of initiatives that are
innovative and should result in improving the patient experience in the coming year e.g. OArm scanner.
The commissioners were pleased to see the planned developments and priorities for 2013 /14
build on the excellent work in 2012 /13 whilst being aware of further improvements required.
The quality priorities are relevant and meaningful for the Trust with clear outcomes identified.
These have been identified through consultation with staff and patients and key stakeholders.
The CCG would recommend that the identified priorities have milestones aligned to them so
they can be monitored through the CQRM over the next twelve months. The improvement
priorities have also been clearly described and linked to each domain for quality.
We look forward to working with The Royal National Orthopaedic Hospital during 2013 /14
on areas highlighted in their Quality Accounts
NHS Barnet Clinical Commissioning group
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
Statement from Harrow
Healthwatch
The draft Quality Account was reviewed by Harrow Overview and Scrutiny Committee on April
16th 2013.
Healthwatch Harrow is currently being established, we are therefore unable to provide any
comments to make a useful input within the time frame suggested; however we look forward
to provide a suitable response to subsequent QA reports.
Ash Verma
Interim Chair, Healthwatch Harrow
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
73
RNOH Charity
74
In 2012, the Royal National Orthopaedic Hospital launched a Redevelopment Appeal with the
goal of raising £15m from philanthropic donations within five years. The funding will add to
£90m in PFI funding towards the first phase of a major redevelopment of the Hospital's
Stanmore site.
Success will see the accommodation unit for the families of children receiving treatment
replaced, enhanced and expanded; it will also allow the redevelopment of the rehabilitation
unit for patients with life-changing injuries such as spinal cord damage. Additional priorities
include enhancements to the Children and Young People's Ward, Imaging Centre, Spinal Cord
Injury Centre, and the Hospital grounds.
We want to design and construct a truly world-class, innovative healthcare environment that
will bring real improvements in orthopaedic care and transform the lives of our patients.
To date
over £2.5 million
has been raised towards the Appeal.
For further information about these projects, please visit www.rnohcharity.org, or contact the
Fundraising Office on 020 8909 5362.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
The RNOH fundraising office has had a very busy year. Highlights of the past 12 months have
included:
• The official launch of the Redevelopment Appeal at St. James's Palace.
• Princess Eugenie becoming the RNOH Appeal Patron, and speaking publicly about
supporting the RNOH Charity for the first time.
• The launch of the RNOH Charity website.
• Princess Eugenie undertaking a sponsored cycle challenge in aid of the Appeal, and
appearing in a Sky News interview to promote her involvement with the Charity.
• The production and official launch of the RNOH Appeal film.
• The Duke of York being actively engaged in promoting the RNOH and trying to secure
unding partners.
• Bear Grylls, David Holmes, Phil Packer and Naomi Riches becoming RNOH Appeal
Ambassadors.
• Princess Eugenie visiting the children's ward during Christmas, which secured extensive
media coverage in the national press and online.
• Passing the £2,500,000 mark in our drive to raise £15 million for the new hospital.
• The 2012 Buttercup Walk raising a record amount – £47,000.
• The creation of the Charity’s own Facebook page and Twitter account.
For further information, please contact Rosie Stolarski, head of fundraising on 020
8909 5468, email fundraising@rnoh.nhs.uk or visit www.rnohcharity.org
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
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Trust opinion
76
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
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The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
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The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
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The Royal National Orthopaedic Hospital NHS Trust Quality Account 2012/13
If you have any comments about this leaflet or would like it translated into another language/large
print, please contact the Clinical Governance Department on 020 8909 5439/5717.
Royal National Orthopaedic Hospital NHS Trust
Brockley Hill
Stanmore
Middlesex
HA7 4LP
www.rnoh.nhs.uk
13-89 © RNOH June 2013