Patient Safety
Patient Experience
Making the most of Musgrove
TAUNTON AND SOMERSET NHS FOUNDATION TRUST
Quality Report 2012/13
Incorporating the Quality Account
Part one
Foreword - From the Chief Executive
As Chief Executive, I am passionate about the quality of the service we provide to our patients at
Musgrove. Quality drives our strategic ambitions and guides the hospital to make the right
decisions about the services we provide so we can continue to deliver the very best levels of care
to the community we serve. Quality is central to everything we do and is an integral part of the
three principles that staff adhere to here at Musgrove:
Patient Safety - to keep our patients safe from avoidable harm.
Patient Experience - to give our patients the best experience possible while they are in our care
so that at least 95% of patients rate the care we provide as ‘excellent’.
Making the Most of Musgrove - to run the hospital as efficiently as possible, at a cost of 10%
less than the average hospital in England, by making sure every penny we spend delivers the
best levels of care and clinical outcomes for all patients.
These have been our guiding principles at Musgrove for a number of years, and they will continue
to be, because they encapsulate the three areas we know we need to focus on if we are to deliver
quality care to our patients. Staff at Musgrove live and breathe these principles and use them to
shape and make improvements to the services they provide; from staff working on the wards, in
clinics and in theatres, to staff working in our support services and management teams.
Our focus on quality has resulted in us achieving some excellent results this year. Our Intensive
Therapy Unit (ITU) has been singled out as achieving the lowest mortality (death) rates in the
country, when compared to ITUs of a similar size, meaning it is one of the safest ITUs in England.
Our infection control rates are also exemplary and are a testament to the hard work of our staff
who continuously strive to keep our patients safe from harm.
We have a lot to be proud of here at Musgrove. However, you will see by reading this year’s
quality accounts there are areas where we have not met the quality targets we set for ourselves,
for example, ensuring every patient that needed help with eating received it and halving our rate
of avoidable hospital acquired grade two pressure ulcers.
There is no room for complacency in these areas and it is vital that during 2013 we continue to
make improvements. As the findings of the Francis Report show, complacency and a lack of
reality about the quality of the service that health organisations provide ends with disastrous
consequences. I have been deeply distressed by the contents of this report and my thoughts
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Patient Experience
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remain with the individuals and their families and carers who have been affected by the poor
quality of care delivered at Mid Staffordshire.
Although I recognise that staff working at Musgrove are extremely dedicated to their patients as
well as their patients’ families and carers, I also know that we do not get it right for every patient,
every time and it is crucial that as an organisation we, like all of the NHS, acknowledge that no
hospital or care setting is immune to failures.
To ensure we learn from and act upon the Francis Report a team of staff from across the hospital;
including healthcare assistants, nurses, doctors and board members are looking closely at the
findings and recommendations to see where changes and/or improvements need to be made at
Musgrove. This team will also be looking at how we listen to our staff, to ensure they feel
comfortable and supported to raise any concerns they have at the earliest opportunity; particularly
about the quality of care being provided.
I know that being passionate about the quality of care we provide only results in excellent
performance when we listen to, and act upon, feedback from our staff. In June 2012, over 340
members of staff from across the hospital attended a number of ‘Big Conversations’. The Big
Conversations marked the beginning of a fundamental shift in the way we lead and work at
Musgrove using the excellent and established techniques of our Improvement Network to put our
staff - the people who know the most - at the centre of change.
Based on what staff said at these events we identified 12 ‘quick wins’ that if implemented would
make an immediate difference to both patients and staff. I am pleased to say these ‘quick wins’
were completed by September.
In September, we went on to launch six enabling projects, which were set up to look at solving
some of the more complicated issues that affect staff across the hospital, and the ‘first 10 teams’
who have been working in their own areas to improve patient care and staff satisfaction.
Since September, more and more teams have been inspired to use this way of working and many
have held their own ‘mini conversations’ which they have used to identify what’s getting in the way
of providing the very best levels of care to patients and their families in their areas. The feedback
we have had from staff about this way of working is that they feel valued and listened to and
empowered to get on and make improvements for the benefit of patients, their families and our
staff; all with the knowledge that they have the full backing of our Improvement Network and the
Board.
To the best of my knowledge, the information contained in the quality report is accurate and I
hope you find our quality accounts informative and useful. I would like to hear your opinions on
how we run our services and any improvements you think we could make.
Signed………………………………………………………………
Jo Cubbon
Chief Executive
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About Us
Musgrove Park Hospital is part of Taunton and Somerset NHS Foundation Trust.
We are the largest General Hospital in Somerset and serve a population of over 340,000. Each
year 40,000 patients are admitted as emergencies; 10,000 patients are admitted for elective
surgery; 26,000 are seen for day case surgery; 232,000 patients attend outpatient appointments;
48,000 attend accident and emergency and over 3,000 babies are born in the maternity
department. In addition 170,000 diagnostics tests are carried out and almost 1,000 patients are
admitted to critical care each year.
We have an annual budget of nearly £240m. The hospital has over 700 beds, 30 wards, 15
operating theatres, an intensive care and high dependency unit, a medical admissions unit and a
fully equipped diagnostic imaging department. Our purpose built cancer treatment centre includes
outpatient, chemotherapy day care, and radiotherapy and inpatient facilities. Musgrove Park also
has a specialised children’s department including a paediatric high dependency bay and provides
Neonatal Intensive Care for all of Somerset. The Trust employs over 4000 staff.
Musgrove Park has three clear principles: Patient Safety, Patient Experience and Making the
Most of Musgrove. We are committed to delivering the safest possible patient care; the best
possible experience for patients and making the very best use of the resources we have.
Some of our achievements in 2012/13
Environment & Services
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We were given Trauma Unit designation as part of the new specialist trauma network in the
NHS South region. We are therefore designated to provide emergency care to patients with
life threatening injuries.
Our Beacon Centre (Cancer Centre) won the CHKS’ International Quality Improvement
Award.
We were given a gold star for our state-of-the-art operating theatres. The National Audit of
Laparoscopic Theatre Equipment 2012 awarded us the highest grade for our integrated
theatres, which meet the most stringent standards of safety and design.
We installed a new £1.5 million CT scanner at Musgrove. This scanner is the first of its kind in
the West of England and can provide a head-to-toe scan in about ten seconds, without the
patient having to be moved.
The Jubilee Building was ‘topped out’ in style to mark the completion of the building’s highest
point.
We were awarded £600k by the Department of Health to enable us to make improvements to
our maternity unit.
Patient Experience
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We were one of only three hospitals in the South West to score five out of five for patients’
privacy and dignity, the hospital environment and its food.
We were recognised as an Outstanding Hospital by the Care Quality Commission (CQC).
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Safety
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We were shortlisted for a national Patient Safety Award. Musgrove was nominated in the
‘Changing Culture’ category, reflecting the hospital’s work in putting patients at the heart of
everything it does.
The proportion of patients surviving infection (sepsis) rose, despite increasing numbers of
patients being diagnosed with the condition. The ‘surviving sepsis’ team were shortlisted for a
Health Service Journal (HSJ) Award in patient safety for their excellent achievements in this
area.
National statistics showed that our cardiology team was one of the quickest in the country for
the speed with which a patient undergoes emergency heart surgery following a heart attack.
Dementia
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Staff from Wordsworth Ward transformed part of the ward to create a tranquil environment for
their elderly patients.
Following the success of the dementia-friendly environment created in Sedgemoor Ward, we
bid for and were awarded £150k from the National Dementia Challenge Fund which will
enable us to similarly improve the environment on an orthopaedic ward during 2013.
We set up a completely new process for screening older patients with memory problems to
assess their risks of dementia and enable onward referral to specialist services which,
through the dedication of team seconded from other roles, has achieved remarkable results.
Our staff
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The dedication and hard work of our staff were recognised at our very own MAFTAs
ceremony (Musgrove Awards for Tremendous Achievement).
A new team of Governors were welcomed to Musgrove following an election campaign.
Representatives for the Taunton Area, West and East Somerset and the area outside the
county were selected, alongside Staff Governors.
We celebrated 5 years of being an NHS Foundation Trust.
Our epilepsy nurse specialist, Teresa Smith, was shortlisted from over 150 nominees for the
Claire Rayner Patient’s Choice Award.
Our Intensive Therapy Unit was recognised by a national independent survey as one of the
best in the country for its mortality (death) rates.
Putting our staff – the people who know the best - at the centre of change
In June 2012, Jo Cubbon, Chief Executive of Musgrove, hosted a number of Big Conversations
with staff from across all levels and roles in the organisation.
These conversations were set up to give staff the chance to talk openly about what gets in the
way of delivering the very best levels of care to our patients and their families. The absolute focus
of these conversations - and the actions that followed – were to support and enable staff to make
changes which would make us all feel satisfied and proud of the service we provide at Musgrove.
Over 340 members of staff from across all groups and levels attended the Big Conversations.
Based on what staff said at these events we identified a number of ‘quick wins’, ‘enabling projects’
and ‘first 10 teams’ to drive improvement and unblock the frustrations that stop staff delivering the
very best care to patients.
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Between July and September 2012, with direct involvement from staff, we identified and
completed 12 ‘quick wins’. In September, we launched six ‘enabling projects’ to look at solving
some of the more complicated issues that affect staff across the hospital as well as the ‘first 10
teams’ who have set up improvement projects in their areas.
Everyone involved in the ‘enabling projects’ and ‘first 10 teams’ are fully supported by the
Improvement Network and have the full backing of the Trust Board to get on and make changes
for the benefits of our patients, their families and our staff.
We are using this way of working to put staff - the people who know the most - at the centre of
change; with the next 20 teams ready to launch their improvement projects imminently.
In addition to the Big Conversations, the Chief Executive continues her regular breakfast
meetings with clinical managers and specialists where they are encouraged to share the issues
that concern them. The senior nursing team spends one day a week on the wards listening to
patients and supporting sisters and their teams to deliver compassionate care in line with clinical
standards. This process enables the senior nurses to take focused action with ward staff. Actions
have included a focus on rounding to ensure patients are regularly repositioned and their skin
inspected to prevent development of pressure ulcers; correct and timely responses to changes in
clinical observations; and responding with staff to concerns about patient care.
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Part Two: Priorities for improvement and statements of assurance from the
Board
Quality - The Patient at the Heart of Everything We Do
Strong leadership is essential within a successful organisation and as reflected in our strategic
objectives our Board is committed to ensuring the hospital provides safe quality care to our
patients. During 2012/13 we have continued to make considerable progress on embedding
quality at all levels of the organisation. At each Board meeting in addition to finance and
performance reports our Board receives a quality report which is produced by the Medical
Director and the Director of Governance and Nursing. This is supplemented each quarter by a
more detailed report covering a wider range of topics including patient complaints and concerns.
The Board has also listened to patient experiences from patients or carers themselves. These
quality reports provide the Board with information on performance with respect to a variety of
quality indicators and issues that are important to us and our patients.
In addition executive and non-executive Board Members take the opportunity to get out on the
“shop floor”. This can be working alongside staff or taking part in regular “walkabouts” visiting
different areas of the hospital, speaking to staff seeing the care given first hand and bringing back
issues which require action.
Through our quality framework we have established quality monitoring across the hospital
reporting to Divisional Boards through to the Governance Committee, a sub group of the Board.
This ensures we continually monitor the quality of care and during this process of on-going
assessment and review we involve our commissioners, Musgrove Partners (lay people) and of
course the Governors.
Stakeholder Involvement
We are fortunate in the Trust to have a strong history of working with our patients, volunteers and
members of the public which helps us to understand their experience of our care and what
aspects they feel we can do better. We are continuing to develop these relationships recognising
they provide us with rich information to assist us in the development of our clinical priorities. Our
Governors’ work-stream on “Patient Care” has been valuable in highlighting the views of the
membership and suggestions on the content and format of this report. In addition, the Trust’s
quality priorities and indicators have been informed by patients, carers, staff and members of the
public, through their involvement in patient feedback interviews, feedback from exit cards,
inpatient surveys and focus groups. We also use information from complaints and calls to our
Patient Advice Liaison Service. We hold quarterly quality monitoring meetings with our
Commissioners which ensures clear agreement on our priorities which are reflected in this report.
Taunton and Somerset NHS Foundation Trust has published Quality Accounts for three years
now and developed a system for establishing quality priorities. Firstly, a long list is drawn up,
informed by the Trust’s performance over the past year against its quality and safety indicators;
external priorities; and finally from horizon scanning. For example, last year the Trust drew from
its performance scorecard topics including patients’ recommending the Trust to friends, falls and
pressure ulcers; and from national priorities VTE and infections. The long list of ten topics was
discussed and consulted on with groups of external and internal stakeholders to develop a
shortlist. The process included involving members of the Governance Committee and Trust’s
Patient Care Group, the result of which became the substance of public online survey. The results
were presented to the Patient Care Group and agreed by members of the Governance
Committee. Many topics have been continued since last year and all topics will continue to be
reported on from ward to Board throughout the year.
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Quality Improvement Priorities 2012/13
In last year’s Quality Report we identified the following five priorities for 2012/13:
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Sustaining the reduction of Hospital Acquired Infections
Improving patient safety whilst in hospital by reducing falls and pressure ulcers
Ensuring patients receive adequate and nourishing food
Caring for patients with dementia
Improving how well we communicate.
The next few pages set out our performance against these priorities. The Board were keen to
ensure that our targets were challenging and stretched the organisation, which meant that not all
targets were achieved. However, in every case the experience has led us to greater
understanding and clear identification of the way forward. We have been able to identify what
measures are the most effective and have been able to refine these for the future. The Board
received regular updates on progress and they have been shared throughout the Trust.
Some of these priorities will remain priorities for 2013/14 following agreement when the Quality
Account was made available to Board members for comment in March 2013. However, all the
topics will continue to be monitored by the Trust Board and we plan to continue to report on them
in future years.
Sustaining the reduction of hospital acquired infections
Methicillin Resistant Staphylcoccus Aureus (MRSA) Blood stream Infections
Our aim was to have ideally zero but no more than one MRSA Trust apportioned case (specimen
taken on or after the third day of admission in line with the standard national definition), as agreed
with our commissioners. The Trust had no cases of MRSA bloodstream infections in 2012-13.
This was achieved by continued MRSA screening of all patients, emphasis on hand hygiene and
scrupulous care of invasive devices.
Clostridium difficile Infection (CDI)
Clostridium difficile infections relate to patients aged two years old or more with a positive test
result recognised as a case according to the Trust’s diagnostic protocol. Positive results on the
same patient more than 28 days apart are reported as separate episodes, irrespective of the
number of specimens taken in the intervening period or where they were taken, and the Trust is
deemed responsible. This is defined as a case where the sample was taken on the fourth day or
later of an admission to the hospital and where the day of admission is day one.
We wanted to have zero but definitely no more than 44 cases of CDI Trust apportioned cases
(specimen taken on or after the fourth day of admission in line with standard national definition),
as agreed with our commissioners. The following graph demonstrates performance against
trajectory.
The Trust had 19 cases in 2012-13 which was a marked decrease on the 37 cases that occurred
in 2011-12. Incidence of cases in the Trust is below the national and regional averages.
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C Diff Trajectory Analysis – April 12 to March 13
Data from Health Protection Agency via IC Net
This reduction was achieved by sustaining the bundle of improvements implemented from
September 2011, which included:
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Further reductions in the use of high risk antibiotics.
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Daily review of patients with CDI by microbiologist and IP&CT, to support
management and isolation practice.
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Annual deep cleaning programme of wards and enhanced cleaning of rooms with
Hydrogen peroxide vapour to eradicate C diff spores.
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Continued Investigation of all cases to identify leaning and drive further improvements.
medical
Improving patient safety by reducing falls and pressure ulcers
The Trust set some challenging safety targets for the year for both falls and skin care with the
expectation that education and focus on these subjects would bring us closer to our and patients’
expectation of safety.
Falls
Our aim was to achieve a 10% reduction in the number of falls in hospital that cause harm from
the level of 28 patients affected in 2010-11 (0.15 per 1,000 bed days). We achieved a 13%
reduction in the number of patients that fell as there were 25 patients harmed as result of a fall
whilst in hospital during 2011-12, equating to 0.13 patients per 1,000 bed days. This target was
achieved by increasing education to staff, use of safety crosses measuring days between falls
and introducing regular patient safety rounding.
In 2012-13 we achieved further reduction: 20 falls equating to a rate of 0.10 per 1,000 bed days.
In addition, a second aim was to achieve 95% of patients being assessed on admission and for all
patients 95% should have the appropriate falls bundle implemented in full except where the
assessment was documented within the forms used by the multidisciplinary team. We achieved
the target for risk assessment completed on admission with 95.5% and for patients at risk of falls
90.0% had the appropriate bundle implemented. Falls reduction was achieved in part by
introducing a revised assessment form, intervention bundles, education and focus on the subject.
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Data from Nursing Metrics database
Falls bundle implementation: the following graph shows that the target for appropriate care
bundle implementation was achieved in some months but not overall and work is continuing to
improve consistency across all wards. This will be led by the designated ward based Falls
Champions that have received additional training.
Falls care plan completed for patients in at risk group
100%
Target: 95%
90%
80%
70%
April 2012
May 2012
June 2012
July 2012
August
2012
September
2012
October
2012
November
2012
December
2012
January
2013
February
2013
March
2013
Data from Nursing Metrics database
Improvements Achieved:
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Implementation of the new patient falls risk assessment and evidenced based staged
bundles in all wards.
Main part of the rollout completed, with ward staff and champions being supported by
trainers from the falls operational group.
Falls Intranet page developed and launched. This contains national and local falls
information and links, in addition to the local falls policy, relevant paperwork, audit tools
and referral forms to refer patients to community services.
A series of Falls Champion training days have been run with high levels of positive
feedback.
Established robust links for other NHS, social care and private sector providers through
the Somerset Falls Network.
Further improvement identified
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To complete the ‘mop up’ areas in the roll out as these need individual modifications /
additions to the bundles due to the nature of the patients and environment;
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To include the new falls process measures into the nursing metrics;
Continue to implement an on-going training plan to support the Falls Champions;
Monitor the frequency and severity of falls;
Continue to investigate the root cause of each fall that causes harm;
Investigate situation and look at improvements in linking in with community services to
ensure referral on to on-going care for falls management on discharges.
Skin Care
Our aim in respect of skin care was that we could reduce hospital acquired pressure ulcers of
grade 2 severity (superficial ulcer, abrasion or blister) or above by 50% (target 0.9% per 1000 bed
days). The 2011-12 rate was 1.14 per 1000 bed days. In 2012-13, the Trust averaged 1.26
pressure ulcers per 1000 bed days with 243 grade 2 or above hospital acquired pressure ulcers
reported. This equates to around 20 patients affected each month.
Although we did not achieve the 50% reduction, there was a sustained increase in the overall
number of pressure ulcers reported in 2012-13. There was a decrease in the number of hospital
acquired pressure ulcers however, where the average number of patients affected reduced from
19 per month in 2010-11 to 18 per month in 2011-12. For the full year April 2011 to March 2012
the overall number of pressure ulcers reported was 696 of which just under one third (218 –
31.3%) were hospital acquired.
‘Hospital acquired’ for this Trust means harm caused by pressure ulcers that occur during a
patient’s stay in Musgrove Park Hospital. The nursing quality measures introduced in 2010
provided focus on the process of assessing patients’ skin and putting in place actions to prevent
pressure damage. This resulted in an increase in the numbers reported and the accuracy of
reporting which has been sustained.
In 2012 the Matrons implemented a root cause review of every hospital acquired grade 2 severity
pressure ulcer which has enabled us to better understand the causes. Chief among these were
staff not being consistent in undertaking skin reviews and position changes. In addition the
Matrons were able to identify a number of cases where skin breakdown was unavoidable due to
patients’ conditions or patients’ preferences not to accept the preventative treatments offered.
Although this meant that we were unable to achieve our goal for 2012-13, we are more confident
that the right actions are taken from the moment patients arrive in hospital and with regular skin
review during their stay.
Rate per 1,000 bed days
The following graph reflects the attention given to this priority which included on-going staff
education and monthly validation of incident reports by Matrons which began in December 2012
to ensure correct and accurate data is recorded.
Data source: Ulysses Incident reporting database (validated)
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In addition we now know that in 2012-13 the proportion of patients in hospital with pressure ulcers
reduced from one third being hospital acquired down to one quarter. We are working with our
partner organisations in the community to alert them to the safety issues for those patients
admitted with pressure ulcers. The average number of patients in 2012-13 developing hospital
acquired pressure ulcers rose slightly to 20 per month.
Over the year we purchased additional pressure relieving mattresses and seat cushions to meet
the increasing need of our patients which is assessed regularly through the collection of individual
patient risk scores. These risk scores inform our equipment purchasing plans.
Source: Incident database (Note: This measure excludes records with no grade established.)
Improvements Achieved:
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Continued implementation of two-hourly patient rounding that includes skin inspection to
aid early identification of problems at pressure points such as heels and sacrum.
Education for ward staff about the key actions to take to prevent pressure ulcers.
Continued use of safety crosses to provide visual information on each ward about the
number of days since the last hospital acquired pressure sore.
Root cause analysis of every hospital acquired pressure ulcer rated grade 2 or above.
Further improvement identified:
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The Trust Improvement Network supporting a Pressure Ulcer Collaborative to focus the
attention of all professional groups on prevention.
Purchase of more pressure relieving equipment.
Sharing information with community staff to improve early recognition of pressure ulcers
in all care settings and learning from other organisations.
Involving ward staff in the investigation and learning from each case of hospital acquired
pressure ulcer.
Ensuring patients receive adequate and nourishing food
Our aim for patients receiving sufficient food within or outside of mealtimes focused on ensuring
those who needed assistance with eating reported that they had been helped. We set a 95%
target for this. Our second target set at 100% and related to ensuring wards hold a range of
appropriate snacks and they could access hot foods day or night. These targets were set in the
context of improving assistance to patients between and at mealtimes by ensuring they could
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reach their food and drinks, by opening packaging, offering finger foods or by fully helping them to
eat where this was needed.
Help with eating
In 2012/13 the percentage of patients surveyed each month reporting they had received
assistance with eating, all or most of the time, where this was required was 92.1% against a
target of 95%. Just missing this stretching target was disappointing and the results reflect a period
Percentage
in the summer of 2012 of poorer results where the Trust experienced challenges in ward staffing
levels followed by a trend of improvement since October 2012 following recruitment.
Data Source: inpatient survey results
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Total
number of
patients
Apr -12
Numbers of patients reporting against this question each month are tabled below. Where dips
showing negative responses have occurred, results have been checked with the wards concerned
to raise the issue of ensuring assistance is offered. A further question is now being asked in the
monthly surveys to find out, if patients aren’t getting help, what sort of help they would like. The
findings from November 2012 were reviewed but nothing of note was found. Increasing numbers
of participants in most months over the year provides a more representative sample of patients.
31
31
23
18
14
26
28
48
18
58
71
121
Access to appropriate snacks
An audit of food and drink availability at ward level was undertaken in 2012. It found that out of 30
wards/patient areas, 27 (90%) demonstrated access to the standard range of snacks, fortified
drinks and hot foods. Of the 17 key food/drink items, five areas had all the items and 26 out of 30
areas audited had at least 15 items. A repeat of this audit is planned for 2013.
There were a number of gaps in equipment provision, for example seven wards did not have a
microwave. A working group of the Nutrition Steering Group has produced a list recommended
food and drink items. There is recognition of variability in ward provision for different patient
groups, which the Catering Liaison Manager will agree with individual Ward Managers.
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Improvements Achieved:
 Sub-groups of the Nutrition Steering group have developed work-streams to focus activity on
improvement which includes a range of teaching and learning opportunities.
 A successful Nutrition Week was led by one subgroup. Nearly 400 staff attended awareness
sessions and wards were involved in creating displays around Nutrition. Through the
campaign, entitled ‘Nutrition Early Action Taunton (NEAT), each ward was asked to pledge
their commitment to Nutrition, by signing posters displayed on their ward. Tray inserts were
created to highlight key messages to patients.
 A range of guidelines and policy were published including The Food, Nutrition, Hydration &
Health Policy; and guidelines related to specific patient groups.
 Continued review of performance in the Nutrition Nursing Metric – March 2013 performance:
89% compliance with questions related to evidence that patients’ risk of malnutrition is
assessed and appropriate actions have been implemented.
 A subgroup of the Nutrition Steering Group has been undertaking ‘Mock CQC’ inspections
involving visiting wards at lunchtime to observe practice and then interviewing both patients
and staff. Ward nurses are advised at the time of the outcome. The findings from the mealtime
visits show considerable variability between wards and these are discussed with Matrons and
ward areas with the aim sharing best practice and increasing consistency in practice.
 Training for doctors and nurses on checking the safe placement of naso-gastric feeding tubes.
 Audit of the food availability and modified diet provision on the Stroke Unit. Work is on-going to
source better breakfast options. Some improvement in snack provision has been achieved.
Further improvement identified:
 The Nutrition Steering Group plans to complete a Trust wide audit on one day to ensure
patients’ nutritional needs are assessed within 48 hours of admission
 Five Mealtime Volunteers have now been recruited and trained. They will work on three wards,
as a pilot programme. A range of guidance and training has been created to support the
introduction of the mealtime assistants. If the introduction of the volunteers is successful more
will be recruited to work in other wards.
 Pictorial menus are being created to support patients with Dementia or those with
communication difficulties.
 The Ward Food Folder introduced in 2012 will be evaluated by the Catering Liaison Manager.
 The Nutrition Champions programme continues to support ward-based staff.
Caring for patients with dementia
Our aim for this topic was to develop a screening process for dementia for all patients aged 75 or
over admitted to hospital. For those at risk we planned to use a set of tests to confirm the
diagnosis and also to establish processes for ensuring and measuring timely referral to dementia
services and specialists. The form with the screening question leads into the assessment itself.
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The screening question asks if the person has had significant problems with their memory over
the previous six months.
We achieved our aim of developing a format for screening and assessment and a system for
onward referral to specialist services. The results demonstrate success in all three parts of the
process.
Assessment of patients at risk
A target was set within the national Dementia CQUIN (Commissioning for Quality Improvement)
framework for us to achieve 90% by the year end of patients aged 75 or over admitted as
emergencies to be screened within 72 hours of admission to hospital.
Between April and June 2012 we developed a system to identify the patient group and to collect
data using the national screening question about memory loss. By fourth quarter we had achieved
66.2% of the patient group being screened which is below the target set for this quarter. It has
been accepted nationally that 72 hours gives insufficient time to test for dementia as patients are
often still too unwell for the test questions to be answered.
Data Source: Unify returns
Confirming diagnosis
A set of tests to confirm diagnosis has been agreed nationally and these are in place for use for
patients that are deemed at risk for dementia. Having set up the system for screening patients for
risk of dementia, from August 2012 we implemented the diagnostic tests and compliance quickly
rose to the level of 90%. Further support from the dementia team will determine the sustainability
of this level of compliance.
Data Source: Unify returns
Referring patients to specialist services
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The process used to refer patients to specialist dementia services is a recommendation to the
patient’s GP at the point of discharge. We met our target earlier than expected of referring 90% of
those identified as at risk and consistently achieved 100% compliance from end of 2012.
Data Source: Unify returns
Improvements achieved:

Quality checking notes of all admitted patients in the age group every day.

Acting for every patient admitted with a known dementia to prompt adaptations to care
and to compile a list of carers to be contacted for feedback on their experiences.

Follow up for all those discharged without screening recorded, by recalling and reviewing
the medical notes and taking action if required.

Acting on those with repeated admissions for Consultant Geriatrician review and report to
the discharge action/patient flow groups.

Inputting all completed screening into Cerner (Electronic Patient Record) and flag those
with known dementia on Cerner.

Reviewing all discharge summaries for outcome of screening i.e. do they get a diagnosis?
The Mental Health liaison nurse for Older People is following up those referred to GP for
outcome. Cerner is updated with results.
A dedicated Dementia Team has also completed (and continues training) with doctors, nurses,
ward-based dementia champions and support staff e.g. therapists, on the importance and value of
good screening and how to make it meaningful.
With a re-organisation and refocus of the Dementia Strategy Group we had a very successful
Peer Review in January 2013 where they commended the significant progress made over the
past 12 months stating ‘the impressive achievements to date of the hospital dementia team and
Strategy Group’; most notably:

The team has provided strong leadership, organisation and drive to deliver a focused
work programme;

Clearly empowered Dementia champions - to be proactive, through their support and
encouragement of a ‘can do’ culture;

The training/education programme seems robust and increasingly embedded;
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There are examples of clear pathways and leadership;

The volunteering within the elderly care wards works well, with a clear plan for spread.
The introduction of activity and personalising bed spaces with clear ownership for testing
this change;

Many changes to the environment have been achieved with modest investment. The art
work across the hospital, the developing use of appropriate signage, the opportunities for
patients to eat away from their bed area, all indicate that the South West standard on
environment is being implemented and is making a difference to the quality of care.
Further improvement identified

Successful in our Bid as part of the ‘Dementia Friendly Community in Somerset Project’
we have been awarded £150K to make environmental changes to an acute orthopaedic
ward. The right environment for the care of dementia patients is a key part of Musgrove
Park Hospital’s strategy for being a dementia friendly hospital. This work will inform the
future design and build work of all environmental projects in the hospital and part of the
design strategy.

Roll out actions across the hospital 24/7 and to assure the progress attained is sustained
going forward.

Continue training and incorporating new areas.
Improving how well we communicate
The aim last year was to reduce the number of written complaints about communication from the
2011-12 baseline which averaged seven complaints per month.
A decrease of 1.1 was achieved to 5.9 complaints per month in 2012-13.
Number of complaints about communication
FY 2012
FY 2013
10
Average
Average
5
0
Data Source: Ulysses Complaints database
In addition to measuring complaints about communications, we continue to monitor the timeliness
of written discharge summaries sent to GPs. Averaging around 90% over the year, in March
2013, 89.6% of discharge summaries were sent within 24 hours of discharge. Where electronic
transfer is available at the receiving GP practice, this is the preferred method of information
transfer.
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Data Source: database
The National Inpatient Survey 2012 identified the Trust as being in the top twenty of hospitals for
ensuring patients receive copies of letters sent between hospital doctors and GPs. Our result for
patients reporting that they had not received a copy of this letter was 16%, half the national
average of 34%.
The Trust recognises the importance of timely and clear communications with patients and is
keen to improve its administrative systems to reduce the level of complaints and concerns raised
both by patients and staff. Our aim in 2012 was to undertake a review of administrative systems
to understand the problems, put in place changes to improve and by doing so to make processes
better for patients and staff.
The Administration Excellence Programme identified six key priorities for 2012/13:






Eliminate delays in clinical correspondence
Improve “customer care”
Streamline and standardise administrative processes
Reduce outpatient cancellations
Improve timeliness and accuracy of outpatient appointment letters
Improve outpatient call handling.
Improvements achieved:
One of the principle performance measures was a reduction in complaints and PALs concerns
relating to these areas. Overall, these have fallen from 73 in quarter one, to 53 in quarter two and
39 in quarter three.
In terms of written communications specifically, a number of actions have been undertaken which
has contributed to this improvement:

Completion of Medical Secretary work-force review and on-going recruitment into vacant
posts;

Increase in Apprentices and development of Advanced Apprentice role;

Revised performance framework introduced to monitor and manage typing workload;

Contact details on patient letters and website updated;

Standard Operating Procedures developed for both medical secretarial and clinical staff;
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
Improvement projects underway in Cardiology and Urology as part of Musgrove’s
Improvement Network to improve the timeliness of communicating results of
investigations to patients and GPs;

Pilot implementation of partial booking system for mutually agreeing the date of follow up
appointments with patients in Paediatrics, Vascular Surgery and Rheumatology. Phased
roll out to other specialties to be continued throughout 2013/14 in order to reduce the
number of hospital and patient cancellations;

Telephone clinic appointment letters amended to improve clarity;

Technical solution developed to identify any appointment letters generated but not printed
to ensure all letters sent patients.
Further improvement identified:
A key development which will further reduce the time taken to produce letters for patients and
GPs is the implementation of a new clinical correspondence and workflow solution which is
currently being piloted in Spinal Surgery and Cardiology. The system will be put in place in every
specialty by September 2013 and will enable letters to be sent electronically to GPs. The
feasibility of offering letters to be sent securely to patients will also be explored as part of this
solution next year.
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Quality Improvement Priorities: 2013-2014
In April the Trust Board agreed the following Key Quality Improvement Priorities for 2013-14:






Sustaining the reduction of hospital acquired infections
Improving patient safety whilst in hospital by reducing falls and pressure ulcers
Staff knowledge and meal provision
Caring for patients with dementia
Improving how well we communicate
Managing emergency admissions.
Area for
Improvement
Sustaining the reduction of Hospital Acquired Infections
Why is this
important?
To ensure a safe environment where patients feel assured regarding hygiene care
whilst in hospital. Our Board and Members Council have asked for this to remain a
priority and our commissioners have set us some expectations.
What do we
want to
achieve?
MRSA: no cases
Performance
to date
Infection Type
C difficile: ideally zero but no more than 15 cases
MRSA
C Difficile
Year
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
No. of cases
36
16
8
8
1
1
0
2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
66
55
48
73
37
19
The increase in C. difficile cases in 2010/11 was due to the Trust implementing a
more sensitive test that also identifies the presence of C. difficile in patients without
symptoms as well as those with symptoms. This test became the norm across all
hospitals in 2012.
Examples of
action being
taken

Early identification and isolation of patients with infections.

Monitoring of infection rates including, staphylococcus, E-Coli and other blood
stream infections, C. difficile infection and surgical site infections. Analysis and
investigation of cases is carried out to inform and drive targeted improvements.

Regular audits of hand hygiene, care of vascular devices and cleaning.

Unannounced hygiene visits to wards by a team of staff including an Executive
Director, Clinical staff and a member of the infection control team are carried out
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on a regular basis. Any areas of concern are highlighted to the ward manager at
the time of the visit and improvements put in place are reported to the Infection
Control Committee by the relevant matron.

Deep clean programme of wards.

MRSA screening of elective and emergency patients.

Restrictions on the use of high risk antibiotics and regular monitoring.
 On-going education for staff, including a dedicated Infection Control Link
Practitioner and Cannula Champion in all clinical areas. How this will
be measured
and
monitored?
Mandatory reporting of MRSA Blood Stream Infections and C difficile cases. In
addition we have a well-established Control of Infection team that monitors and
reports other cases of infection. In depth reviews of individual cases are carried out
to understand how the infection occurred and to identify any learning that may
prevent a similar infection in other patients.
How will this
be reported?
Monthly reports produced and shared within the hospital and reported to the Trust
Board.
Area for
Improvement
Improving patient safety by reducing falls and pressure ulcers
Why is this
important?
To promote an environment where patients feel safe regarding the risk of avoidable
harm occurring whilst in hospital. Pressure ulcer and falls prevention was identified
as a priority in our survey of Trust members and the public.
What do we
want to
achieve?
Falls: to accurately identify the number of falls that lead to significant harm and
reduce by 10% by implementing actions proven to prevent fracture.
Pressure Ulcers: to reduce by at least 40% the number of avoidable hospital
acquired pressure ulcers of grade 2 and above from the year end 2012-13 level.
Performance
to date
Harm type
Falls
Year
No. of cases
2009-10
2010-11
2011-12
2012-13
14
28
25
17
2009-10
122
2010-11
227
2011-12
219
2012-13
243
There was increased focus placed on formally reporting patient falls and pressure
ulcers when the nursing workforce introduced a set of measures called ‘Nursing
Metrics’ in February 2010. These metrics focus on topics felt by the profession to
reflect the quality of nursing care and include falls and pressure ulcers. This
accounts for the increases for both topics seen between 2009 and 2010.
Pressure Ulcers
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Patient Safety
Examples of
action being
taken
Patient Experience
Making the most of Musgrove
 Purchase of additional pressure relieving equipment including mattresses and
cushions to meet changes in identified need.
 Continued use of safety crosses on each ward as visual reminder to patients,
visitors and staff stating the number of days since the last fall or pressure ulcer.
 Implementation and monitoring of formal patient comfort rounds every 2 hours
that includes checking the skin of patients at risk of developing pressure ulcers
and incorporates the basic falls bundle.
 Staff education regarding assessment and the key actions that prevent
falls and pressure ulcers.
 New falls risk assessment with associate stage bundles implemented on all main
wards and basing simple learning tools from cases where unrelieved skin
pressure caused harm.
 Reporting our figures for falls and pressure ulcers nationally using the Patient
Safety Thermometer from April 2012 will enable benchmarking against national
averages.
How this will
be measured
and
monitored?
Dedicated multi-professional groups lead on and monitor falls and pressure ulcers
which are subject to monthly reporting. In depth reviews of individual cases are
carried out to understand how the fall or pressure ulcer occurred and to identify any
learning that may prevent similar events occurring.
How will this
be reported?
Monthly reports produced and shared within the hospital and reported to the Trust
Board.
Area for
Improvement
Why is this
important?
What do we
want to
achieve?
Staff knowledge and meal provision
Nourishment is a key element in recovery from illness or surgery and maintenance
of good health. Our online survey demonstrated that the topic of food and nutrition
was a priority for high quality care and we know we need to continue improving
staff education, food availability and practice. We provide a range of nourishing
foods when patients need it and we aim to ensure that they are given the
assistance they need.
This year we want to focus on staff education and food availability. Our targets for
the year include:
80% of staff will demonstrate an acceptable level of knowledge about food
availability;
95% of wards will have a core range of snacks available;
90% of patients will report they have received help with eating all or most of the
time, where this was required.
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Patient Safety
Performance
to date
Patient Experience
Making the most of Musgrove
27/30 (90%) wards/patient areas demonstrated access to the standard range of
snacks, fortified drinks and hot foods in 2011-12. A repeat of this audit is been
planned for 2013.
An audit of staff knowledge was not undertaken last year.
We will continue the measurement strategy started in 2012-13 for nutritional
screening on admission to hospital, nutritional care planning and the delivery of
nutritional care against these care plans. Target 90% for each parameter:

Nutritional screening for adults – 89.9%

Patients at risk have documented care plans in place for 83.4% of patients

Nutritional interventions were documented for 86.3% of patients.
In 2012/13 the percentage of patients reporting they had received assistance with
eating, all or most of the time, where this was required was 91.0% against a target
of 95%. This question remains part of our monthly survey.
Examples
action being
taken
Dedicated Nutrition Team and team of Dietitians working with patients unable to
eat normally.
Education about nutrition provided to a range of staff groups.
In 2012, a Nutrition Awareness Week was held where nearly 400 ward staff
attended an awareness update session and educational displays were created on
most wards. Also patient meal tray inserts were introduced to provide patients with
information about their nutrition.
Nutritional screening for inpatients on admission to hospital.
Regular nursing rounds to all patients at risk of malnutrition to encourage eating or
consumption of fortified drinks.
Review of catering provision – special menus for patients requiring modified texture
diets have been introduced and new patient menus are in development.
A ward food folder has been introduced on each ward offering information on food
provision and special diets, for both patients and staff to use.
Mock ‘Care Quality Commission’ inspections have been undertaken by a team of
hospital staff to observe mealtimes and the results are shared with Ward Sisters
and Matrons to focus on improvement where needed.
Role of Catering Liaison Manager has been introduced in February 2013, to work
with the wards, the catering team and Dietitians, to further improve patient food
provision, support staff education and monitor quality.
Mealtime volunteers have been recruited and trained to work on three wards
initially. This is proving helpful in ensuring those patients who need extra time to
eat their meals receive it. If successful, the aim is to roll this out across further
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wards in the hospital.
Continuous audit and monitoring.
How this will
be measured
and
monitored?
Audit of staff knowledge – target 80%;
Annual audit of wards with core snacks and foods – target 95%;
Nutritional Screening, Care Planning and Delivery of Care plans: through nutritional
metrics undertaken monthly;
Patients are asked each month if they received assistance with eating if this was
needed – target 95%.
How will this
be reported?
Inpatient survey and nutrition metrics both report position monthly to wards and
Matrons.
Report of food and drink availability and staff knowledge about food availability to
the Nutrition Steering Group.
Quarterly report to Trust Board.
Area for
Improvement
Why is this important? Caring for patients with dementia
Nationally, there is widespread concern about the care of people with dementia in
the general hospital setting. It is estimated that 25% of general hospital beds in
the NHS are occupied by people with dementia, rising to 40% or even higher in
certain groups such as elderly care wards or in people with hip fractures. The
presence of dementia is associated with longer lengths of stay (an average of
seven extra days compared to patients with similar primary diagnoses but no
dementia), delayed discharges, readmissions and inter-ward transfers. DOH 2012.
The dementia challenge was launched in March 2012 by Prime Minister David
Cameron and we are committed to transforming to a ‘dementia friendly’ hospital.
In 2012/13 there was the National Dementia CQUIN setting Acute Hospital Trusts
the target to screen for dementia in the 75 years+; and a local CQUIN to achieve
the South West Hospital Standards in Dementia Care – Level Two What do we want to achieve? In 2012 we committed the funding to set up the Dementia Team for 12 months to
the focus the action needed to implement the National Dementia CQUIN, the local
Dementia CQUIN, national audits e.g. anti-psychotic prescribing and to respond to
opportunities for improving dementia care through national funding released as
part of the Dementia Challenge Initiatives. It was our aim to put in the foundations
in place for the hospital to become a ‘dementia friendly’ hospital.
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Patient Safety
Performance to date Patient Experience
Making the most of Musgrove
National Dementia CQUIN (screening): aiming to screen 90% of patients within
72 hours of admission.
In Quarter 4 of 2012-13 we achieved 66.2%.
Peer Review in January 2013 positive outcome with no gaps and no significant
recommendations.
A letter was received in January 2013 from our commissioners acknowledging the
concern raised nationally about the difficulties in achieving the 72 hour expectation
when many patients are still too unwell to be screened and assessed and
adjusting the expectation to 90% screened during their inpatient episode.
Examples of action being taken The aims of the dementia team to screen and assess patients; train and educate
staff; and make the environment ‘dementia friendly’ for patients, will continue
throughout 2013-14. For example, Wordsworth Ward has provided a quiet area for
patients and the Jubilee Building design has been informed by the dementia group
to ensure the new environment promotes a safe and calm setting for all patients
coming in for planned surgery and particularly for those with dementia. As the
dementia team comes to the end of their 12 month secondment into their roles
they are setting out the resources needed to continue the leadership,
implementation and evaluation.
How will this be Progress against achieving screening 90% of patients is monitored monthly
through the CQUIN monitoring meeting.
measured and monitored? The progress against the hospital’s Dementia Action Plan is monitored through the
Trust’s Dementia Strategy Group monthly meeting: this includes reporting on
leadership; training and education performance; feedback from dementia
champions monthly audits; environmental updates; and all aspects of the care
pathway.
How will this be Status on the CQUINs is reported quarterly to the Trust Board as part of the
Clinical Quality Report
reported? Status on the action plan is reported monthly via the Dementia Strategy Group
which has non-executive and executive members as a part of the membership.
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Patient Safety
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Making the most of Musgrove
Area for
Improvement
Improving how well we communicate with patients
Why is this
important?
This area was highlighted as very important in our public survey of key priorities
to review in year. It relates to how patients feel they are treated when they attend
the hospital or are contacted by staff.
In 2012-13, in more than half of all the formal complaints received, there was
some element relating to communication or concern about staff attitude. These
complaints were often about other things, such as treatment or delays in care,
with the communication concern being one part of a bigger issue. The
experiences mentioned in the complaints included how people felt they were
spoken to face to face or by telephone, or on receipt of written communications,
for example about appointment changes.
The Trust is working hard to improve its administrative functions, including written
communications and the systems that support booking information. Staff training
is key to the success of these improvements.
What do we
want to
achieve?
During 2013-14 we will deliver a values-based training package on
communication skills for administrative and secretarial staff, linked to staff
appraisal, to address staff attitude issues and promote good customer care skills.
This will be supported by implementation of a ‘partial pending project’ for
outpatient appointments to improve bookings and a ‘theatre scheduling project’ in
year
To ensure administrative staff have received customer care training – increase
from 2012-13 baseline.
Decrease in the absolute numbers of complaints and concerns received about
staff attitude and communication in relation to the administrative staff group.
Performance to
date
High level reports about formal complaints seen regularly by the Trust Board
reflect the themes of communication and attitude as areas of concern, along with
a theme of clinical treatment, as demonstrated in the graph below.
Data from Ulysses reporting database
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25
Patient Safety
Patient Experience
Making the most of Musgrove
Whilst a single complaint can have more than one theme, a breakdown by
themes from formal complaints shows a range of issues, as demonstrated in
Oct-Dec 12:
Appointments (cancellations/delays)
7
Attitude of staff
5
Communication/info to patients
21
Diagnosis
5
Discharge
4
Medical treatment
17
Nursing Care
5
Operations (outcome, cancellation, delay)
7
Patients make use of the Patient Advice and Liaison Service (PALS) when
concerned about written or direct communications by hospital staff. In 2012-13
there were 49 PALS concerns and one formal complaint raised about
communication and six PALS concerns and eight formal complaints about the
attitude of administrative staff.

Spread of customer care training.

Bespoke training in specific high risk areas

Learning from complaints spread across the Trust

Patients’ stories shared with staff involved in specific cases.
Examples of
action being
taken
How this will be
measured and
monitored?
To ensure administrative staff have received customer care training – increase
from 2012-13 baseline as a percentage of Trust employees.
Decrease in the absolute numbers of complaints and concerns received about
staff attitude and communication in relation to the administrative staff group.
Progress will be monitored through monthly performance meetings.
How will this be
reported?
Reported quarterly to the Quality Assurance Committee.
Area for
Improvement
Managing emergency admissions
Why is this
important?
The Taunton and Somerset NHS Foundation Trust Board has raised concerns about
the increasing levels of emergency admissions impacting on its capacity to respond
to the demand whilst still providing other services as usual. The graph from hospital
information services demonstrates the upward trend in medical emergency
admissions from April 2010 to March 2013:
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Patient Safety
Patient Experience
Making the most of Musgrove
There has been an increase in emergency admissions of 12% in the last two years
and whilst flexibility in the number of beds we need is managed on a daily basis, the
impact of a further 3% increase on the previous year in medical emergency
admissions in the first three months of 2013 has resulted in opening additional beds
and using surgical beds far more frequently than expected.
This increase has caused challenges for staffing to the correct levels in terms of
numbers and skills of nursing, medical and therapy staff especially out of hours and,
in extreme pressure when multiple patients arrive at the same time, delays to patient
treatment. We have also cancelled some planned surgery to create space for
emergency patients. This situation has been recognised as a significant corporate
risk to providing all of our usual services.
What do we want
to achieve?
To provide safe and effective care for all patients admitted hospital whether as
emergencies or for planned surgery. We aim to do this by working collaboratively with
general practitioner bodies to control the number of emergency admissions, enabling
planned management of inpatient flow and improving bed and staff management. We
will continue to work with primary and social care agencies to provide timely
discharge care. The area where we can have most impact in managing patient flow is
in addressing the issues related to readmissions, rates of which have increased.

Performance to
date
For patients discharged from Acute Medical Specialties, to identify the most
commonly occurring conditions that result in patients being readmitted within 30
days and to take actions that may lead to reducing the readmission rate in each
condition.
Readmission rates for patients previously under a specialty in the Acute Medical
Directorate are increasing as demonstrated in the table below.
Year
Number
2010-11
2011-12
2012-13
1975
2187
2266
The specialties with most readmissions include Cardiology, Gastroenterology,
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Patient Safety
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Making the most of Musgrove
Respiratory and Care of the Elderly.
Medical outlier bed days (the number of days medical patients were cared for in
surgical wards) provide a relevant measure of impact on the hospital’s usual
business. Performance to date shows a rising impact on the hospital’s capacity:
Year
Number
2010-11
2011-12
2012-13
4235
3485
5243
Surgical cancellations for organisational reasons within 24 hours of the planned
procedure provide another relevant measure of the impact of emergency admissions.
Performance shows a trend downwards from 2009-10 with an increase in January
2012-13:
Year
2009-10
2010-11
2011-12
2012-13
Examples of
action being
taken
No.
cancelled
508
493
437
504
Total
planned
admissions
36612
38409
39846
40366
%
cancelled
1.4
1.3
1.1
1.2
Development of a heart failure service to support West Somerset patients;
Remote monitoring of recently discharged COPD patients by the THREADs team;
Working with GPs to develop ambulatory care pathways for appropriate conditions eg
management of deep vein thrombosis;
The development of a Frail Elderly Care Pathway in collaboration with other health
and social care providers in Somerset, supported by our commissioners.
How will this be
measured and
monitored?
Readmission rates are monitored in the Acute Care Directorate monthly reports;
other measures are reported monitored monthly through performance dashboards.
How will this be
reported?
Reported monthly to the Trust Board
National Quality Indicators
In 2013, the Department of Health mandated hospital trusts to strengthen their quality accounts
through the introduction of mandatory reports against a small core set of quality indicators. This
includes providing comparative information to make it easier for readers to understand whether a
particular number represents good or poor performance.
The information on each topic identifies how well we performed in 2012-13, compares this with
national averages and the highest and lowest performing Trusts and includes a brief commentary
explaining our relative performance and steps being taken to improve performance. Topics are
presented within the relevant NHS Outcomes Framework domain. Data is taken from the Health
and Social Care Information Centre (HSCIC) database prepared for this section of the Account.
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Making the most of Musgrove
Summary Hospital-Level Mortality Indicator (SHMI)
Related domain: (1) Preventing People from dying prematurely
The Summary Hospital-level Mortality Indicator (SHMI) is a more recently developed mortality
indicator. It is similar to Hospital Standardised Mortality Ration (HSMR) in some respects, in that it
expresses actual deaths compared to an expected value. In this case, ‘average’ is represented by
a value of 1.00 (not 100, as in HSMR). SHMI has been designed to overcome certain
shortcomings inherent in HSMR, most specifically the influence of coding of palliative care
patients. The index is therefore calculated using somewhat different inputs, but essentially it
provides a similar type of information. It serves as a useful comparator to HSMR, increasing
confidence in our data. Our overall SHMI over the past three years is represented in the table
below.
Rate
Reporting Period
England
(Banding)
Lowest
Trust
Highest
Trust
0.9635
October 2011 to September 2012
1.00
0.8649
1.2107
1.00
0.7108
1.2559
1.00
0.7102
1.2475
(as expected)
0.9631
July 2011 to June 2012
(as expected)
0.9450
April 2011 to March 2012
(as expected)
NB 1.00 is the SHMI average, values lower than 1.00 indicates better than average
The Taunton and Somerset NHS Foundation Trust considers that this data is as described for the
following reasons:

Continued focus on initiatives related to safety and reducing avoidable deaths in a range of
specialties.

Review of Dr Foster data by specialty and at clinician level to provide early warning of
problems in patient care.
The Taunton and Somerset NHS Foundation Trust intends to take the following actions to
improve this rate, and so the quality of its services, by regularly monitoring our outcomes through
tools such as Dr Foster and the NHS Information Centre. Where outcomes appear to be
deviating, this allows verification of validity of the result, and an early opportunity to take
corrective action.
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Percentage of patient deaths with palliative care coded at either diagnosis or specialty
level for the trust
Reporting Period
Percentage
England
Lowest
Trust
Highest
Trust
October 2011 to September 2012
0.2%
18.9%
0.2%
43.3%
July 2011 to June 2012
0.5%
18.4%
0.3%
46.3%
April 2011 to March 2012
0.4%
17.9%
0.0%
44.2%
The Taunton and Somerset NHS Foundation Trust considers that this data is as described for the
following reasons:

The Trust has never excluded palliative care coded deaths from its overall mortality statistics.
The Taunton and Somerset NHS Foundation Trust has taken the following actions to improve this
rate, and so the quality of its services, by

focusing on the quality of its coding practice to ensure palliative care coding is correctly
applied when this is the primary reason for admission to ensure we include all deaths in our
reported statistics. This should improve confidence in our data.
PROMS: Patient Reported Outcome Measures.
Related Domain (3) Helping people to recover from episodes of ill health or following injury
PROMs measure a patient’s health status or health-related quality of life from the patient’s
perspective, typically based on information gathered from a questionnaire that patients complete
before and after surgery. The figures in the following tables show the percentages of patients
reporting an improvement in their health-related quality of life following four standard surgical
procedures, as compared to the national average.
Groin hernia surgery
Reporting Period
Adjusted
average
health gain
England
Lowest
Trust
Highest
Trust
April 2012 to December 2012
0.153
0.090
0.017
0.153
April 2011 to March 2012
0.075
0.087
-0.002
0.143
April 2010 to March 2011
0.075
0.085
-0.020
0.156
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The Taunton and Somerset NHS Foundation Trust considers that this data is as described for the
following reasons:

Majority of patients are treated as day cases
The Taunton and Somerset NHS Foundation Trust has taken the following actions to improve this
rate, and so the quality of its services, by

providing a full pre-operative assessment service to enable early identification of problems for
management prior to admission for surgery and a range of verbal and written information
about the procedure.
Varicose vein surgery
Reporting Period
Adjusted
average
health gain
April 2012 to December 2012
England
Lowest
Trust
Highest
Trust
*
0.089
0.027
0.138
April 2011 to March 2012
0.090
0.094
0.047
0.167
April 2010 to March 2011
0.086
0.091
-0.007
0.155
The Taunton and Somerset NHS Foundation Trust considers that this data is as described for the
following reasons:

There were fewer cases in the last six month period than can be reported without the risk of
patient identification. When sufficient cases are available, a figure will be reported.
The Taunton and Somerset NHS Foundation Trust has taken the following actions to improve this
rate, and so the quality of its services, by

Giving every patient the questionnaire at pre-assessment clinic and encouraging patients
to complete and return the PROMS form.
Hip replacement surgery
Reporting Period
Adjusted
average
health gain
April 2012 to December 2012
England
Lowest
Trust
Highest
Trust
*
0.429
0.328
0.500
April 2011 to March 2012
0.407
0.416
0.306
0.532
April 2010 to March 2011
0.415
0.405
0.264
0.503
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The Taunton and Somerset NHS Foundation Trust considers that this data is as described for the
following reasons:

There were fewer cases in the last six month period than can be reported without the risk of
patient identification. When sufficient cases are available, a figure will be reported.
The Taunton and Somerset NHS Foundation Trust has taken the following actions to improve this
rate, and so the quality of its services by

Giving every patient the questionnaire at pre-assessment ‘Joint Clinic’ where they receive
education about the surgery, what to expect during their recovery and how to manage at
home afterwards, and encouraging patients to complete and return the PROMS form.
Knee replacement surgery
Reporting Period
Adjusted
average
health gain
April 2012 to December 2012
England
Lowest
Trust
Highest
Trust
*
0.321
0.201
0.408
April 2011 to March 2012
0.316
0.302
0.180
0.385
April 2010 to March 2011
0.280
0.299
0.176
0.407
The Taunton and Somerset NHS Foundation Trust considers that this data is as described for the
following reasons:

There were fewer cases in the last six month period than can be reported without the risk of
patient identification. When sufficient cases are available, a figure will be reported.
The Taunton and Somerset NHS Foundation Trust has taken the following actions to improve this
rate, and so the quality of its services, by

Giving every patient the questionnaire at pre-assessment ‘Joint Clinic’ where they receive
education about the surgery, what to expect during their recovery and how to manage at
home afterwards, and encouraging patients to complete and return the PROMS form.
Patients readmitted to a hospital within 28 days of being discharged
Related Domain (3) Helping people to recover from episodes of ill health or following injury
Whilst some emergency readmissions following discharge from hospital are an unavoidable
consequence of the original treatment, others could potentially be avoided through ensuring the
delivery of optimal treatment according to each patient’s needs, careful planning and support for
self-care. Because of the complexities in collating data, national and local rates are reported
nationally 18 months in arrears. This is the first report that includes information about children readmitted to the Trust which show that they are broadly in line with the national average. Our adult
readmission results for 2010-11 indicate that we were significantly better than average. Our 28
day readmission index is 105% which is well within the confidence limits. There are five
Taunton and Somerset NHS Foundation Trust - Annual Report and Accounts 2012/13
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Making the most of Musgrove
diagnoses that are significantly above the expected range but these are small samples and none
has reached significance.
Percentage of patients aged 0 - 14 readmitted to the trust within 28 days of being
discharged
Reporting Period
Percentage
England
(medium
acute
trusts)
Lowest
Trust
Highest
Trust
April 2010 to March 2011
10.68%
10.02%
0%
13.94%
April 2009 to March 2010
9.99%
10.34%
0%
14.44%
April 2008 to March 2009
10.46%
10.25%
0%
17.55%
The Taunton and Somerset NHS Foundation Trust considers that this data is as described for the
following reasons:

We do tend to accept a higher readmission rate because of our strategy to manage as many
cases as possible as ‘ambulatory’ in order to minimize overall admission and length of stay

We are aware that these rates were complicated by the reason for readmission. In this period
some children who had had planned surgery were coded as ‘readmissions’ but were actually
attending for review post-discharge.

Many of these readmissions will have been babies born at Musgrove Park Hospital and coded
as ‘readmitted’ for feeding issues.
The Taunton and Somerset NHS Foundation Trust has taken the following actions to improve this
rate, and so the quality of its services, by:

Being clearer with coding and reducing the number of ward reviews

Implementing a new community midwifery led feeding protocol and assessment to prevent
admissions for ‘poor feeding’
Percentage of patients aged 15 or over readmitted to the trust within 28 days of being
discharged
Reporting Period
Percentage
England
(medium
acute
trusts)
Lowest
Trust
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Making the most of Musgrove
April 2010 to March 2011
10.03%
11.16%
0%
12.94%
April 2009 to March 2010
9.74%
11.05%
0%
13.17%
April 2008 to March 2009
10.11%
10.80%
0%
13.07%
The Taunton and Somerset NHS Foundation Trust considers that this data is as described for the
following reasons:

over a period of three years, the Trust has maintained an overall 28 day readmission rate of
5-15% below the national average for equivalent hospitals

this is indicative of good general care and appropriate clinical judgment with regards to patient
discharges

this is during a period of the stepwise introduction of enhanced recovery programmes in
various specialties, which would indicate that appropriate discharge criteria are being
maintained
The Taunton and Somerset NHS Foundation Trust intends to take the following actions to
improve this rate, and so the quality of its services, by

monitoring more specific readmission rates for various procedures and conditions, as this can
provide information about clinical teams in greater detail. This would allow for improvements
to be directed at the areas that most require them.

applying learning about the causes of readmission through the organisation as a whole, which
can further improve overall performance, including in services not found to be below par.

Staff training to ensure admission details are correctly entered when patients return for wardbased review.
Responsiveness to the personal needs of patients.
Related Domain (4) Ensuring that people have a positive experience of care
Patient experience is a key measure of the quality of care. As part of the NHS we continually
strive to be more responsive to the needs of those using its services, including needs for privacy,
information and involvement in decisions. The organisation’s responsiveness to patients’ needs is
a key indication of the quality of patient experience. This composite score is based on the
average of answers to five questions in the CQC national inpatient survey which is run in July and
August every year:
• Were you involved as much as you wanted to be in decisions about your care and treatment?
• Did you find someone on the hospital staff to talk to about your worries and fears?
• Were you given enough privacy when discussing your condition or treatment?
• Did a member of staff tell you about medication side effects to watch for when you went home?
• Did hospital staff tell you who to contact if you were worried about your condition or treatment
after you left hospital?
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The score for 2012 (69.5) is an improvement on that for the previous year. National data for the
2012-13 period will be available in May 2013.
Reporting Period
Score
England
Lowest
Trust
Highest
Trust
2011/12
68.9
67.4
56.5
85.0
2010/11
69.7
67.3
56.7
82.6
2009/10
68.3
66.7
58.3
81.9
The Taunton and Somerset NHS Foundation Trust considers that this data is as described for the
following reasons:

The Trust scores consistently better than the national average due to the focus placed on
involving patients in decisions about their care at every stage.

In 2012 we focused on ensuring patients were informed about medication they may take
home and our score rose for this question from 44 in 2011 to 44.64 in 2012.

We also saw a slight improvement of 0.7 points from 2011 relating to who patients should
contact should they have any concerns, achieving a score of 64.9 in 2012.
The Taunton and Somerset NHS Foundation Trust intends to take the following actions to
improve this rate, and so the quality of its services, by

Continuing to survey patients against these five questions which form part of the monthly
survey.

Increasing the numbers of patients surveyed on each ward to enable substantial numbers to
support themes for actions as well as for one-off concerns.

Focusing on groups of wards for three months at a time to provide them with rich data to
which from which to take actions to improve.

Continue monitoring the results by the Patient Experience Implementation Group which is
chaired by a patient.

Continue to ensure the results are reported to Trust Board regularly
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.
Related Domain (4) Ensuring that people have a positive experience of care
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How members of staff rate the care that their employer organisation provides can be a meaningful
indication of the quality of care and a helpful measure of improvement over time. The NHS staff
survey includes the following statement: “if a friend or relative needed treatment, I would be happy
with the standard of care provided by this Trust” and asks staff whether they strongly agree;
agree; neither agree nor disagree; disagree; or strongly disagree. Our performance has been
calculated by adding together the staff that agree and strongly agree with this statement.
Our results were broadly in line with last year’s rating of 74% and demonstrate that staff are loyal
and feel proud of the work they undertake despite current feelings about changes in workforce
and caseloads.
Reporting Period
Percentage
Nonspecialist
acute
Trusts
England
Lowest
Trust
Highest
Trust
2012
72%
62%
35%
86%
2011
74%
62%
33%
89%
2010
69%
63%
38%
89%
The Taunton and Somerset NHS Foundation Trust considers that this data is as described for the
following reasons:

Work being undertaken in 2012-13 with staff within ‘Big Conversations’ led by the Executive
team where staff at all levels are encouraged to express concerns and share ideas for
improvement.

Several work-streams have arisen from these events which are supported by the
Improvement Network to ensure actions are taken and that they create improvement.

Changes nationally to the terms and conditions for non-medical staff (known as Agenda for
Change) has raised concerns among staff and for which union support has been active.
The Taunton and Somerset NHS Foundation Trust intends to take the following actions to
improve this rate, and so the quality of its services, by

Continuing the ‘Big Conversation’ approach to engage staff in the development and
implementation of ideas.

Survey the staff regularly to obtains a ‘Pulse Check’ about their views as the Trust as an
employer.

Continue to feed back to employees the outputs of work-streams where staff have been
involved in making improvements.
Patients admitted to hospital who were risk assessed for venous thromboembolism
Related Domains (5) Treating and caring for people in a safe environment and protecting them
from avoidable harm
VTE (deep vein thrombosis and pulmonary embolism) can cause death and long-term morbidity,
but many cases of VTE acquired in healthcare settings are preventable through effective risk
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assessment and prophylaxis. Incidence of VTE is an important indicator of improvement in
protecting patients from avoidable harm, and there is an expectation that patients’ risk of
developing blood clots is risk assessed on admission to hospital. This became a national
Commissioning for Quality and Innovation (CQUIN) topic for 2012-13 with the local expectation
that every clinical area in the Trust could report 90% compliance with risk assessment.
Against the national average our performance was above target in 2012-13.
England
Lowest
Trust
Highest
Trust
Reporting Period
Percentage
October to December 2012
92.7%
94.2%
84.6%
100%
July to September 2012
93.4%
93.9%
80.9%
100%
April to June 2012
92.9%
93.4%
80.8%
100%
The Taunton and Somerset NHS Foundation Trust considers that this data is as described for the
following reasons:

Staff are trained in the protocol for risk assessment when patients are admitted as
emergencies and also for planned procedures.

Every Directorate achieved 90% compliance with risk assessment every month in 2012-13
with the exception of the Acute Care Directorate which contains the main admission wards.
This Directorate achieved 90% for seven out of 12 months.

The Trust relies on a paper-based system to record compliance with the assessments which
can be fallible when key members of the staff who collect the data are away.
The Taunton and Somerset NHS Foundation Trust intends to take the following actions to
improve this rate, and so the quality of its services, by

Pursuing an electronic solution to recording risk assessments from which compliance data
can be reliably obtained. This solution is expected to be in place in 2013.

Continuing to monitor the rate of assessments to meet the 95% compliance level required in
the 2013-14 Commissioning for Quality and Innovation framework.

To continue the work of a dedicated team reviewing the notes of patients identified as having
had a hospital acquired blood clot (deep vein thrombosis or pulmonary embolus) to ensure
correct preventative or treatment actions were taken. These reviews identify learning which is
fed back to clinical teams within the hospital and with community colleagues to share
learning.
Rate of C.difficile infection
Related Domains (5) Treating and caring for people in a safe environment and protecting them
from avoidable harm
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C. difficile can cause symptoms including mild to severe diarrhoea and sometimes severe
inflammation of the bowel, but hospital-associated C. difficile can be preventable. Incidence of C.
difficile is an important indicator of improvement in protecting patients from avoidable harm.
The rate of cases of C. difficile infections is reported rather than the incidence, because it
provides a more helpful measure for the purpose of making comparisons between organisations
and tracking improvements over time. The national average for 2012-13 will not be published by
the Health Protection Agency (HPA) until July this year but we expect our performance to be in
line with the national average because a national standardised testing regime was brought into
use in 2012-13 which will enable comparison with other organisations.
Reporting Period
Rate per
100,000 bed
days
England
Lowest
Trust
Highest
Trust
April 2011 to March 2012*
20.8
21.8
0.0
51.6
April 2010 to March 2011
41.1
29.6
0.0
71.8
April 2009 to March 2010
27.2
36.7
0.0
85.2
*2011/12 rates are based upon 2010/11 HES data
The Taunton and Somerset NHS Foundation Trust considers that this data is as described for the
following reasons:

The lower than national average rate in 2011 reflects early adoption of the now standardised
test which identifies more cases (presence of C difficile as well as active infection).

In 2011-12 we had 37 cases of C. difficile against a local target of 44 and in 2012-13 we had
19 cases against a local target of 44.

A dedicated work-stream working in 2011 identified a bundle of actions that contributed to the
reduction in the rate from the previous year, including early isolation and better antibiotic
prescribing.
The Taunton and Somerset NHS Foundation Trust intends to take the following actions to
improve this rate, and so the quality of its services, by

Continued focus and monitoring of cases that do occur against an aim of no more than 15
cases in 2013-14;

Continued monitoring of prescribing by clinical teams to avoid use of high risk antimicrobials;

Daily review of patients with CDI by the Infection Prevention team to support medical
management.
Patient safety incidents and the percentage that resulted in severe harm or death
Related Domain (5) Treating and caring for people in a safe environment and protecting them
from avoidable harm
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At Musgrove there is a positive culture for reporting incidents. Over 8600 incidents were reported
during 2012-13. Of these, nearly half are classified as patient safety incidents.
Data from Ulysses Safeguard Incident reporting database
Patient safety incidents reported to the National Learning and Reporting System
The National Learning and Reporting System (NRLS) collects and collates information from the
incident databases of health service providers to provide thematic review and share wider
learning about patient safety through a system of safety alerts sent to every organisation.
The Trust’s Safeguard Incident software has an automatic process for uploading its incidents to
the National Learning and Reporting System (NRLS). The upload is run at least twice monthly
and the software then reports any incidents that failed to upload, such as when they did not
include the minimum data set. If we have the required information, we correct the failed incident
report before the next upload. Therefore there is usually a small discrepancy between numbers
reported and numbers accepted.
In the table below and since 2011, there is evidence of increasing numbers of reports being
uploaded to the NRLS database.
Number Reported
to NRLS
Number Accepted
by NRLS
October 2012 to March 2013
2,858*
Data period closes 31
May 13
April 2012 to September 2012
2941**
2,342
October 2011 to March 2012
2144
2,098
April 2011 to September 2011
1897
1,872
Reporting Period
Data from Ulysses Safeguard Incident reporting database
Taunton and Somerset NHS Foundation Trust - Annual Report and Accounts 2012/13
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*NOTE – this figure is the number of incidents that have been submitted so far. The cut-off date
for the reporting period Oct – Mar is 31 May 2013. The NRLS will provide a report on this period
in September 2013.
**For the period Apr-Sep 2012 there is a discrepancy of approximately 600 incident reports that
have not appeared on the NRLS upload to date, the reason for which is being investigated. For
all other periods, numbers reported are confirmed.
The Taunton and Somerset NHS Foundation Trust considers that this data is as described for the
following reasons:

The Trust has been involved in a range of work-streams led by our Improvement Network to
improve specific aspects of patient safety and to reduce incidents;

We actively encourage reporting of incidents to enable learning to be obtained.
The Taunton and Somerset NHS Foundation Trust intends to take the following actions to
improve this rate, and so the quality of its services, by

The requirement to report all patient safety incidents to the National Reporting and Learning
Database has been challenging due to our Incident Database functionality. To overcome this
we plan to roll-out web-based incident reporting which has been piloted successfully in
Maternity and X-Ray departments since August 2012.

The changeover to Safeguard Incident Web provides workflow management and incident
reporting directly into the Safeguard Risk Management System via the Trust’s intranet, giving
easy access to the System. Safeguard Web provides an entry point that is widely accessible
so that incidents can be entered by the staff involved when they happen, avoiding delays in
reporting. Managers can access the information for which they are responsible, having a clear
view of the Incidents that have recently occurred and require action, or the risks that relate to
their areas.
Number of patient safety incidents that resulted in severe harm or death (SIRI)
The NHS National Patient Safety Agency (NPSA) provided the following definitions for severe
harm or death:
Severe – Any unexpected or unintended incident which caused permanent or long-term harm, to
one or more persons.
Death – Any unexpected or unintended incident which caused the death of one or more persons.
October 2012 to March 2013
Number of Severe
Harm / Death
Incidents
16
April 2012 to September 2012
4
0.2%
October 2011 to March 2012
11
0.5%
April 2011 to September 2011
17
0.9%
Reporting Period
% of Incidents
Reported
Data from Ulysses Safeguard Incident reporting database
Taunton and Somerset NHS Foundation Trust - Annual Report and Accounts 2012/13
40
0.6%
Patient Safety
Patient Experience
Making the most of Musgrove
The Taunton and Somerset NHS Foundation Trust considers that this data is as described for the
following reasons:

Up to September 2012 period there has been a sustained reduction in incidents that cause
serious harm or death in line with several streams of patient safety work started in 2007.

Patient safety work-streams have focused successfully particularly on reducing serious
incidents related to delays in escalation for treatment and patient falls.
The Taunton and Somerset NHS Foundation Trust has taken the following actions to improve this
rate, and so the quality of its services, by

A range of work-streams led by our Improvement Network to improve specific aspects of
patient safety and to reduce incidents.

Improvements have also been made in the quality and general approach to investigation,
giving more credibility to the recommendations means better clinician engagement with the
improvement agenda.

Encouraging reporting and greater consistency in the rating of incidents.
Statements of Assurance from the Board
Review of Services
During 2012-13 the Taunton and Somerset NHS Foundation Trust provided, or sub-contracted,
forty-nine relevant health services:






Acute adult and paediatric care
Maternity Services
Accident and Emergency treatment
Diagnostic Services
Elective and emergency services
Cancer care and radiotherapy.
The Taunton and Somerset NHS Foundation Trust has reviewed all the data available to them on
the quality of care in all 49 of these relevant services.
The income generated by the relevant health services reviewed in 2012-13 represents 100% of
the total income generated from the provision of relevant services by the Trust for 2012-13.
Part Three of the Quality Account provides an overview of our achievements and progress within
quality indicators that have been selected by us and our stakeholders including CQUINs. The
data reviewed covers the three dimensions of quality – patient safety, clinical effectiveness and
patient experience. We indicate where the amount of data available for review has impeded this
objective.
Information on participation in clinical audits and national confidential enquiries
During 2012-13, 38 national clinical audits and two national confidential enquiries covered
relevant health services that Taunton and Somerset NHS Foundation Trust provides.
During 2012/13 the Trust participated in 92% of national clinical audits and 100% of national
confidential enquiries of the national clinical audits and national confidential enquiries in which it
was eligible to participate.
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National Audit Participation
The national clinical audits and national confidential enquiries that 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 that audit or enquiry.
These are as follows:
National Audit Title
Participated Coverage
Acute coronary syndrome or Acute
myocardial infarction (MINAP)
(subscription funded from April 2012)
Yes
100%
Adult critical care (Case Mix Programme
– ICNARC CMP)
Yes
100%
Bowel cancer (NBOCAP)
(Subscription funded from April 2012)
Yes
100%
Cardiac arrhythmia (HRM)
Yes
Notes
Child health programme (CHR-UK)
Yes
100%
Coronary angioplasty
(subscription funded from April 2012)
Yes
100%
Diabetes (Adult) ND(A)
Yes
100%
National Diabetes Inpatient Audit (NADIA)
Yes
100%
Diabetes (Paediatric) (NPDA)
Yes
100%
Elective surgery (National PROMs
Programme)
Yes
Epilepsy 12 audit (Childhood Epilepsy)
Yes
(Also known as the Child Health Clinical
Outcome Review Programme)
All eligible cases are
being submitted
All consenting cases are
submitted
100%
Taunton and Somerset NHS Foundation Trust - Annual Report and Accounts 2012/13
42
Patient Safety
Patient Experience
National Audit Title
Making the most of Musgrove
Participated Coverage
Head and neck oncology (DAHNO)
(subscription funded from April 2012)
Yes
100%
Heart failure (HF)
(subscription funded from April 2012)
Yes
100%
Inflammatory bowel disease (IBD)
Notes
4th round data collection
started in January 2013
Yes
Lung cancer (NLCA)
(subscription funded from April 2012)
Yes
100%
Maternal, infant and newborn programme
(MBRRACE-UK)
Yes
100%
National Cardiac Arrest Audit (NCAA)
No
n/a
National Comparative Audit of Blood
Transfusion - programme includes the
following audits, which were previously
listed separately in QA:
a) O neg blood use (2010/11)
b) Medical use of blood (2011/12)
c) Bedside transfusion (2011/12)
d) Platelet use (2010/11)
Yes
100%
National Joint Registry (NJR)
Yes
100%
National Review of Asthma Deaths
(NRAD)
Yes
100%
National Vascular Registry (elements
include CIA, peripheral vascular surgery,
VSGBI Vascular Surgery Database, NVD)
Yes
100%
Neonatal intensive and special care
(NNAP)
(subscription funded from April 2012)
Yes
100%
Previously took decision
not to take part due to
subscription costs and
limitations in reporting.
(For review within 2013)
All received
questionnaires
completed and returned
All applicable cases
submitted
Taunton and Somerset NHS Foundation Trust - Annual Report and Accounts 2012/13
43
Patient Safety
Patient Experience
National Audit Title
Making the most of Musgrove
Participated Coverage
Oesophago-gastric cancer (NAOGC)
(subscription funded from April 2012)
Yes
100%
Paediatric asthma (British Thoracic
Society)
Yes
100%
Sentinel Stroke
National Audit Programme (SSNAP) programme combines the following
audits, which were previously listed
separately in QA:
a) Sentinel stroke audit (2010/11,
2012/13)
b) Stroke improvement national audit
project (2011/12, 2012/13)
Yes
-
Severe trauma (Trauma Audit &
Research Network, TARN)
Yes
100%
Adult community acquired pneumonia
(British Thoracic Society)
Yes
-
Bronchiectasis (British Thoracic Society)
Yes
100%
Emergency use of oxygen (British
Thoracic Society)
Yes
100%
National audit of dementia (NAD)
Yes
100%
Non-invasive ventilation - adults (British
Thoracic Society)
Yes
-
Pulmonary hypertension (Pulmonary
Hypertension Audit)
No
n/a
Adult asthma (British Thoracic Society)
Yes
100%
Carotid interventions audit (CIA)
(subscription funded from April 2012)
Yes
100%
Notes
Data collecting from
01/02/13
Data collecting at
present
Data collecting at
present
Decision taken not to
participate due to
volume of cardiac
audits. Patient group
largely treated
elsewhere.
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Patient Safety
Patient Experience
National Audit Title
Making the most of Musgrove
Participated Coverage
Notes
Fractured neck of femur (COEM)
Yes
100%
Hip fracture database (NHFD)
Yes
100%
Paediatric fever (College of Emergency
Medicine)
Yes
100%
Paediatric pneumonia (British Thoracic
Society)
Yes
Data collecting at
present
Yes*
100%
*Participated but not for
all 3 phases due to
service configuration /
management changes
No
n/a
Took part in previous
years, recommendation
is to take part every
other year to allow
embedding of changes
Yes
100%
Pain database
Parkinson's disease (National Parkinson's
Audit)
Renal colic (College of Emergency
Medicine)
National Audits falling outside the scope of the Trust’s services
These projects were active within the period but relate to service types other than those the Trust
provides, included for completeness:
Title
Participated Coverage Notes
Adult cardiac surgery audit (ACS)
Congenital heart disease (Paediatric
cardiac surgery) (CHD)
No
n/a
The procedure is not
performed
No
n/a
The procedure is not
performed
No
n/a
The Trust does not have
a stand-alone Paediatric
intensive care unit
Paediatric intensive care (PICANet)
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Title
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Participated Coverage Notes
Prescribing Observatory for Mental
Health (POMH)
(Prescribing in mental health services)
No
n/a
For mental health
service providers
Renal replacement therapy (Renal
Registry)
No
n/a
Trust is not a specialist
centre
Mental Health programme: National
Confidential Inquiry into Suicide and
Homicide for people with Mental Illness
(NCISH)
No
n/a
For mental health
service providers
Intra-thoracic transplantation (NHSBT
UK Transplant Registry)
No
n/a
Trust is not a specialist
centre
National audit of psychological therapies
(NAPT)
No
n/a
For mental health
service providers
No
n/a
Not considered relevant
as Trust is not a
specialist unit – for
review during 2013.
No
n/a
Trust is not a specialist
centre
Potential donor audit (NHS Blood &
Transplant)
Renal transplantation (NHSBT UK
Transplant Registry)
National Confidential Enquiries with active participation during 2012-13
Name of Confidential Enquiry
Coverage
NCEPOD Sub-arachnoid Haemorrhage study
Notes
100%
NCEPOD Tracheostomy study
-
Currently underway
The Trust’s response to national and local audit findings
The reports of the national clinical audits were reviewed by the Trust in 2012-13 and the Trust
intends to take the following actions to improve the quality of healthcare provided:
Paediatric Asthma (British Thoracic Society (BTS))
The Children’s Unit has put in place actions responding to the 2011 BTS report and will use the
2012 data to verify the impact of these improvements, when published. Work to increase uptake
of the asthma care plan documentation is complete. Work is continuing to ensure consistent
provision of advice sheets, to accompany children with wheeze home following an admission. The
Trust’s guideline is under review, to ensure that clear requirements for information-giving to
parents are stated. A further structured plan is in place to respond to the Paediatric Pneumonia
National Audit, also led by the BTS.
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Paediatric Diabetes
The National Paediatric Diabetes Audit reported in the latter half of 2012 and development actions
have been defined, in line with current service developments linked to Best Practice Tariff
requirements and recent Peer Review of the service. Amongst these planned changes will be the
introduction of annual clinical reviews and the introduction of point of care testing to improve
HbA1C level monitoring and improved access to / uptake of insulin pumps. The Trust’s plans
have been submitted to the Regional Network Group Chair for endorsement at the next meeting.
Heart Failure
Significant service development has been planned by the Cardiology Department within the 12-13
period to establish an Integrated Heart Failure service in Somerset. This leads from both the prior
rounds of the National Heart Failure Audit and in respect of NICE Guidelines and Quality
Standards. This work is focused on establishing Nurse-led Heart Failure Liaison Clinics for which
a business case has been approved. A framework for Commissioning for Quality and Innovation
(CQUIN) measurement has been developed which is directly based upon the NICE Quality
Standard statements. Further rounds of National Audit will also be reviewed to assess the impact
of these changes.
Childhood Epilepsy (‘Epilepsy 12’)
Whilst many of the findings have provided positive assurance that the Trust’s service for children
with epilepsy compares favorably with national benchmarks, with credit to the work of the
Epilepsy Nurse Specialists in post, further improvements are identified in the services plans: One
particular challenge is to improve the recording of a specific epilepsy syndrome using the
recognized classification system. Provision of update training for senior medical staff is planned to
ensure accurate assessment methods are used and appropriate information is recorded. Plans
are also in place to improve consistency in the use of ECG in line with NICE recommendations,
and to enhance the rate of referral for tertiary review (to the Bristol unit).
Current developments to our arrangements for review of reports
Further national audit reports, recently including Lung Cancer and Stroke, have been reviewed at
a newly established Data Review Group. Co-ordinated by the Trust’s Governance Support Unit,
the group brings together the expertise of key people, including the Lead for Data Quality, Clinical
Quality Analyst, Head of Integrated Governance and Medical Lead for Governance. This offers an
opportunity to develop an understanding of what the audit data is telling us about quality and to
effectively direct attention to those areas requiring an improvement response.
The reports of 85 local clinical audits were reviewed by the Trust in 2012/13. Action plans are
developed for all audits where significant issues are identified and the Trust intends to take
actions to improve the quality of the healthcare provided. Amongst these are the following
responsive actions, as an illustration of the service-specific development work initiated via audit
during the 2012-13 period.
Improving the availability of suitable food (snacks) and drink options for inpatients
The Trust has assessed how well it is meeting the standards defined by the Care Quality
Commission and other agencies for ensuring snacks and drinks are available to inpatients outside
of mealtimes. The audit has provided a basis for agreement of the Trust’s own minimum
standards and communication of these expectations throughout the hospital, engaging ward
managers. The developments will continue into 2013.
Evaluating the Trusts success in establishing a new Binge Eating Disorders Group
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Lead by the Obesity Dietician with input from a clinical psychologist, the project measured
outcomes for attendees at a new support group for people living with Binge Eating Disorder. The
development was part of the Trust’s implementation of the NICE Clinical Guideline for obesity
interventions. Whilst improvements were demonstrated in terms of patient’s mental health status
and binge eating habits, opportunities to refine the service and improve uptake were identified.
This included arranging group meetings in the evening and improving screening to better detect
patients most likely to benefit. Further measurement is planned into 2013.
Assessing the use of contrast media in pelvic radiotherapy scans
The radiotherapy team, based within the Beacon Cancer Centre, has undertaken an assessment
of contrast use when performing pelvic radiotherapy scans. The findings support the use of the
contrast as a useful element of scanning for this patient group. It has additionally provided a basis
for it to now also be used for rectal radiotherapy scans. This extended use will then be further
audited to assess usefulness as a means to plan appropriate treatment.
Auditing the operation of the Trust’s protocol for Emergency ENT ward attenders & ENT
emergency clinic provision
The Ear, Nose and Throat consultant team wanted to assess the provision of adequate clinic
capacity. The audit provided the information needed to initiate uplift in capacity to three clinics a
week and to provide a Junior Doctor-lead emergency access clinic as a new development.
Assessing patient experience, while receiving treatment at the phototherapy unit
The Junior Sister Leading the phototherapy service recognized that capturing feedback about
patient experience was an integral part of continually improving quality. Even though overall the
feedback has been extremely positive, there are some areas where improvements have been
identified: These include improving the information given to patients about their prescribed
treatment. In response, two leaflets have been produced, to be sent out with the routine
correspondence. More accurate measurement pre and post treatment has also been introduced,
allowing improved evaluation of treatment effectiveness. Further developments to the clinical
environment are being explored and follow up appointments are now given to patients on their
last treatment session.
Ensuring national guidance is followed in Neuro-rehabilitation
Actions leading from an audit of the management of spasticity included production of patient
information, to be given ahead of the treatment with botulinum toxin (‘Botox’) injections. Remeasurement is planned for 2013.
Information on participation in clinical research
Taunton and Somerset NHS Foundation Trust’s main contribution to the national Research and
Development (R&D) strategy lies in the recruitment of patients into externally-funded and
externally-led multi-centre trials, and other well designed studies, in particular those adopted on to
the National Institute of Health Research (NIHR) Portfolio. Our overall ambition is to provide a
wide ranging, and sustainable research infrastructure and vibrant research culture that maximises
the opportunities for all patients to enter research projects relevant to their particular condition.
The number of patients receiving NHS services, provided or sub-contracted by the Trust in 201213 that were recruited during the period to participate in research approved by a research ethics
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committee was 1581 (NIHR Portfolio). This is a 58.1% increase on the plan of 1000 set out in last
year’s report. Although overall a lower number than in 2011/12; as noted in last year’s report the
2011/12 figure of 1970 was skewed by one very high recruiting study that represented
approximately 70% of the total.
The number of NIHR portfolio studies that recruited patients in the period has consistently
increased year on year over the last five years and increased by 15.0% from the 80 reported in
2011/12 to 92 in 2012/13. This increasing participation in NIHR portfolio clinical research
demonstrates the Trust’s commitment to improving the quality of care we offer and to making our
contribution to wider health improvement. This is largely facilitated through our clinical trials unit or
dedicated research-nursing staff embedded in clinical areas.
During the reporting period the Trust used national systems to manage the NIHR portfolio studies
in proportion to risk. The monthly median time to complete the risk checks using these systems
was continuously within the NIHR’s monthly 30 day target for which the Trust was consistently
RAG rated green by our local NIHR Comprehensive Local Research Network (Western CLRN).
The Trust’s Critical Care research team won an award for ‘best validated data’ from the Sponsors
of one of the clinical trials they are participating in known as ProMISe, which is comparing
treatments for emerging septic shock. Unlike the foregoing this is pleasingly a measure of quality
as opposed to quantity.
We continue to host the Taunton and Somerset Research & Development Consortium, which
provides a research management and governance service to both the Trust and to NHS
Somerset (now Somerset Clinical Commissioning Group), and facilitates a link between primary
and secondary care research, particularly in the respiratory and cardiology areas. The Trust also
hosts the coordinating centre of the NIHR Research Design Service – South West.
Information on the use of the Commissioning for Quality and Innovation (CQUIN)
Framework
A proportion of the Trust’s income in 2012-13 was conditional on achieving quality improvement
and innovation goals agreed between Taunton and Somerset NHS Foundation Trust and
Somerset Primary Care Trust, through the Commissioning for Quality and Innovation payment
framework.
In 2012-13, the anticipated income, conditional upon achieving the quality improvement and
innovation goals, was £1,100,000. Although in 2011-12 the Trust and commissioners had agreed
quality and improvement topics, there was no financial incentive agreed for that year.
Key leads were identified for all of the indicators and a monitoring group was established to
review progress on a monthly basis.
The Trust’s overall compliance is monitored by
commissioners and discussed in detail at the quarterly clinical quality review meetings. Good
progress has been made across all areas.
Information relating to registration with the Care Quality Commission (CQC)
The Care Quality Commission is the independent regulator of health and adult social care
services in England. They also protect the interests of people whose rights are restricted under
the Mental Health Act.
The CQC carries out their responsibilities by
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



Patient Experience
Making the most of Musgrove
Driving improvement across health and adult social care
Putting people first and championing their rights
Acting swiftly to remedy bad practice
Gathering and using knowledge and expertise, and working with others.
Full information on the CQC can be found on their website.
Taunton and Somerset NHS Foundation Trust is required to register with the Care Quality
Commission, and our current registration status is registration with no conditions.
The Care Quality Commission has not taken enforcement action against Taunton and Somerset
NHS Foundation Trust during 2012-13.
The Trust has participated in a periodic review by the Care Quality Commission which visited at
the end of July / beginning of August 2012 for a three day inspection to assess the Trust against
six key Outcomes. The inspectors visited 12 wards and four clinical departments and the Trust
was found to be meeting all of the required standards, with no compliance actions required.
The Outcomes reviewed were:
Outcome 01: People should be treated with respect, involved in discussions about their care and
treatment and able to influence how the service is run;
Outcome 04: People should get safe and appropriate care that meets their needs and supports
their rights;
Outcome 07: People should be protected from abuse and staff should respect their human rights;
Outcome 14: Staff should be properly trained and supervised, and have the chance to develop
and improve their skills;
Outcome 16: The service should have quality checking systems to manage risks and assure the
health, welfare and safety of people who receive care;
Outcome 21: People's personal records, including medical records, should be accurate and kept
safe and confidential.
As part of the inspection, the CQC followed up on issues relating to Outcome 21 (record keeping)
that had been previously flagged at an inspection in March 2012 relating to the termination of
pregnancy service. The Trust had been required to take some actions to ensure compliance and
the inspectors confirmed that these had been completed satisfactorily.
Information on quality of data
The Trust is committed to ensuring that the data we use to measure our performance is accurate.
We have an Information Governance Steering Group that receives and monitors information on
data quality. This group is supported by a specific Data Quality Steering Group with the remit to
coordinate all data quality activity into a Trust-wide framework. The Trust will be taking the
following actions to improve data quality:
1) Ensuring core training is carried out to improve the quality of the data collected to:

Provide the foundation for a programme of monitoring and improvement

Establish consistency with NHS data definitions and use of information
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Support the information governance agenda.
2) Strengthening the data quality process by creating a centralised, prioritised data quality
issues log and by re-focusing the existing Data Quality team on the top priorities.
3) Through a dedicated communications plan, raising awareness throughout the organisation on
the key data quality issues and the impact they have.
Taunton and Somerset NHS Foundation Trust submitted records during 2012-13 to the
Secondary Uses Service (SUS) 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: Accident and
Emergency
care Admitted
Patient
Care Outpatient
Care % of valid NHS Numbers received from BT 98.56
99.43 99.83
% of valid NHS Numbers sent to SUS 99.23
99.84 99.94
% of valid GP Practice Codes received from BT 100
100 100
% of valid GP Practice Codes sent to SUS 100
100 100
- which included the patient’s valid General Practitioner Code Data Source: Information Centre Data Quality Dashboard (figs based on Apr-Feb 12/13 SUS
data).
Compared to the previous year the percentage of valid NHS numbers received from BT has
remained at around the same level, whilst the percentage of valid practice codes has fallen
slightly. The percentage of valid NHS numbers submitted to SUS has improved slightly, whilst the
percentage of valid practice codes submitted to SUS has remained at 100%.
Compared to the previous year this shows an overall improvement for valid NHS numbers from
the previous year which were

89.3% for accident and emergency care

97% for admitted patient care

98.9% for outpatient care.
Information Governance
Taunton and Somerset NHS Foundation Trust’s Information Governance Assessment Report
overall score for 2012/13 was 85%, and was graded green with a rating of satisfactory.
The Trust was in the top thirteen of 161 Trusts for compliance with these standards.
Clinical Coding error rate
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The Trust was subject to the Payment by Results clinical coding audit during the reporting period
by the Audit Commission in August 2012. The locally determined specialty for review was Oral
Surgery, with half from the admitted patient episodes and half from the outpatient file. The
selection was taken from the data submitted to the Secondary Users Service and the results are
as below.
Regarding the admitted patient audit the headline results demonstrate above 90% compliance
across all standards with the exception of the secondary procedure coding. This can be
explained by a misunderstanding of the National Standards around laterality coding for Oral
Surgery.
As for the outpatient audit, the episodes audited were only just within the time where the
outpatient coding had started in this Trust, and therefore the sample available to the auditors was
too small to show an accurate position.
As before, these results should not be extrapolated further than the actual sample audited, and
work has already been undertaken to improve on the lower scores.
Taunton and Somerset NHS Foundation Trust was subject to the Payment by Results clinical
coding audit during the reporting period by the Audit Commission and the error rates reported in
the latest published audit for that period for diagnoses and treatment coding (clinical coding) was:
Area audited
% of
episodes
correct HRG
(Healthcare
Resource
Group)
Oral Surgery
APC
Oral Surgery
Outpatient
% Procedures coded
correctly
Primary
Secondary
92.0
89.8
70.0
N/A
100.0
N/A
% of spells
correct HRG
(Healthcare
Resource
Group)
% Diagnoses coded
Primary
Secondary
91.9
92.1
80.8
82
N/A
N/A
Taunton and Somerset NHS Foundation Trust will be taking the following actions to improve data
quality:
Recommendation 1
Address training needs for existing staff.
Recommendation 2
Introduce arrangements for new coders that provide adequate support
and monitoring of their output to ensure appropriate data quality is
maintained.
Recommendation 3
Re-audit laterality in light of improved approach to using world dental
federation notation.
Recommendation 4
Ensure the outpatient procedure policy is fully mandated across
outpatients and ensure the accountability for adhering to the new
procedure coding policy is clearly defined within each clinical department.
Recommendation 5
Improve the existing procedure coding policy so that it provides specific
guidance for each individual clinical area, including maxilla-facial and oral
surgery.
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Recommendation 6
Clearly define “shared care” and “multidisciplinary” clinics and update the
coding policy to cover the correct use of the X62 assessment code to
identify this activity.
Recommendation 7
Clearly define and implement a policy on how to identify the correct
treatment function codes of clinics within oral surgery (140) and maxillofacial (144), supporting clerks in implementing this correctly; and review
processes to support accurate treatment function code allocation in other
clinical areas.
Part Three
Other information
As this report has shown, the safety of our patients and the quality of care is of paramount
importance to all who work in the Trust. This section provides an overview of the quality of care
offered by The Trust and some of the work we are currently developing.
Improvement Network
Since the launch in February 2011, the Improvement Network has been developing the capacity
and capability of Musgrove staff to make improvements in the way we deliver care for our
patients.
The Improvement Network uses a ‘collaborative’ approach which is to bring teams together so
that there is joint sharing and learning and the opportunity to ‘cross-pollinate’ ideas within the
Trust. The focus is strongly linked into the strategic aims of Musgrove which is measured by:



95% of our patients rating the care they receive at MPH as excellent
Zero avoidable harm to patients
Reference costs for are below 90.
Improvement Network – Wave 1
March – October 2011
Wave 1 brought together most of the improvement projects within Musgrove at the time, these
can be divided into innovation e.g. dementia care, piloting e.g. Enhanced Recovery in Colorectal
Surgery, and spreading e.g. Acute care –Sepsis. 11 out of the 12 teams had demonstrable
improvements.
Improvement Network –Wave 2
January – July 2012
This wave focused on spreading the principles of Enhanced Recovery to other surgical specialties
both within both the elective pathway – micro-discectomies, pacemaker insertion, lower limb
amputations and gynecology surgery, and within the emergency pathway – fractured neck of
femur.
Improvement Network –Wave 3
June 2012– February 2013
Two Big Conversations were held in the summer of 2012, which were attended by over 350 staff.
Based on what staff said at these events 12 ‘quick wins (which would impact on both patients and
staff) were identified and successfully implemented. Six enabling projects, which were set up to
look at solving some of the more complicated issues that affect staff was launched, as well as the
‘first 10 teams’ who have been working in their own areas to improve both patient care and staff
satisfaction.
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Improvement Network- Wave 4
March –December 2013
As part of this wave, there will be both a collaborative which will be focus on the challenge of
eradicating hospital acquired grade 3 and above pressure ulcers at Musgrove Park. This is due to
be launched on March 13th, and will have all adult inpatient wards represented. In addition 10
frontline teams will start their journey on patient and staff improvements. The teams are listed
below:
COPD and Pneumonia care bundles Surgical move to Jubilee Building
Radiotherapy workforce Critical care outreach – the future Smoking on Musgrove site Dunkery Ward
Diabetes inpatient care Gould Ward Nursing documentation Centralized cleaning services The Leadership Talent Programme
We reported last year on the development of a leadership programme. Staff members are our
biggest resource and greatest asset and it is, therefore, important that we use their skills and
expertise in the best possible way. Phase 2 of the ‘Leadership Matters Programme’ started in
September 2012 with 60 senior managers participating.
Over the two years of the programme, we have put through 110 senior managers of which 41
have been Senior Consultants which equates to 37% of the cohort. The programme continues to
be a great success with this year, the coaching element of the programme being extended from 3
to 6 sessions. In May 2013 a middle management programme will be starting to equip the middle
managers within the Trust with the leadership skills required to deal with the challenges of
working in a modern healthcare organisation. This programme will be a platform for those leaders
within the Trust wanting to continue to the senior leadership programme.
In addition to the formal leadership programme, a regular development programme has been in
place for ward sisters and clinical team leaders.
Listening to Staff
Musgrove introduced ‘Schwartz Rounds’ in November 2011 with support for the first year from the
Kings Fund. The rounds introduce a structured monthly one-hour forum for staff from all
disciplines to discuss the human and emotional side of clinical care. These rounds are an
opportunity for all who attend to participate in facilitated discussion. They provide a supportive
space for staff to reflect on the challenges of providing care to patients and their families.
So far we have held 10 rounds with about 280 attendees from all disciplines of which 33% of
attendees were from Nursing and Midwifery, 15% from Medical and Dental, 30% from therapy
staff and 22% from other staff groups. We have seen rounds presented by The Chief Executive,
the Medical Director as well as Specialist teams and the rounds have covered many different
topics from uniting together as a team, through to breaking bad news. The feedback from the
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rounds is always really positive with 49% of attendees having attended four or more of the rounds
and people stating that they have found the rounds useful and it has helped them to reflect.
Staff Survey 2012
The 2012 NHS Staff Survey shows that the overall staff engagement survey result for the Trust
has risen from 3.64 in 2011 to 3.74 in 2012. This is better than average compared to other acute
trusts. Alongside the engagement score the Trust is also placed in the top 20% of trusts on the
following:



Effective team Working
Support from immediate line managers
Staff reporting good communication between senior management and staff.
All of the above have been supported by the work that has taken place and started with the ‘Big
Conversations’ that were held in 2012 where Executives and staff meet to share staff concerns
and to develop work-streams that address the issues. The Improvement Network structure then
supports and monitors the teams’ progress and enables feed-back to the wider organization.
Patient Safety Walk Rounds
We continue our programme of patient safety walk rounds within the hospital. All Executive
Directors are invited to participate, demonstrating top level commitment to patient safety and
experience. This process enables front line staff to share best practice and celebrate successes
in their clinical area. It is also an opportunity for the teams to discuss patient safety issues that
cause concern to the team and to work on actions to resolve the concerns. On average there are
two walk rounds achieved each month. The whole process impacts on and improves
communication between Ward and Trust Board. Feedback comments from all involved have
been positive. Actions derived from the Walk Round are followed up within a three month window.
Patient Experience - Learning from Concerns and Complaints
Feedback from our patients and their families is very important. This helps us to continuously
learn and improve what we do. During the year we received 247 formal complaints and 1,349
concerns which were raised through the Patient Advice and Liaison Service (PALs).
All of these concerns are investigated and feedback given to the person who raised the concern,
this includes setting out what we have learnt and any changes made as a result of the concerns
raised.
Notable progress and achievements during the year:

The Trust has participated in a project with the Patients Association seeking feedback from
patients and relatives who have raised a formal complaint. This feedback has significantly
helped the Trust to better understand where we need to improve our complaint handling.
This year has seen a decrease in formal complaints received by 37% compared to last year
and an increase in the number of PALs concerns. Staff across the hospital and in PALs have
worked hard to address concerns proactively at the time and to be responsive to any
concerns raised.

On the 23 January the new “front of house” PALs/information office was opened in the Old
Building. This provides patients, families and the public with an accessible point of contact for
advice and support. Alongside this new leaflets and posters have been produced which
clearly brand PALs and make them more distinct from other information.
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Working in partnership with the Patients Association the Trust was fortunate to have the
opportunity of training provided by the Patients Association to staff directly involved in the
investigation and resolution of complaints.
The Parliamentary and Health Service Ombudsman provides an independent complaints handling
service for a range of public bodies. Should any of our complainants be dissatisfied with the
handling and outcome of their complaint they have the right to request that the Ombudsman
undertakes an independent review of their complaints. We ensure that every complainant is given
information about the role of the Ombudsman. During the year the Trust had 9 new cases referred
and the following decisions were made by the Ombudsman:

2 Local resolution was achieved

3 Ombudsman declined to investigate

1 case withdrawn

3 at time of report being assessed.
The following are just a few examples of the learning and improvements we have made:

One outcome of a complaint in A&E has been to improve the environment for patients
particularly around removing odours as it has been reported that cubicle fans can be
insufficient to clear the air.

Development of volunteer roles to support staff in improving information and support available
to patients in areas such as out-patients.

Learning from a patients discharge and feedback received, the policy for management of
those patients diagnosed with a heart attack has been amended by the Cardiologists.
Quality Indicators 2012-13
The following table provides information by month about our compliance with the CQUIN
framework (Commissioning for Quality Improvement and Innovation). This is followed by a report
on other indicators we use to measure patient safety, clinical effectiveness and patient
experience.
For each section in the table, the upper row indicates the target and the colour indicates whether
we met the target (green) or did not achieve it (red). Reporting on the CQUINS with a red rating:

In the responsiveness to patient needs CQUIN, although we improved our score from 2011 by
0.6 points in the National Inpatient Survey, we missed improving by the 0.8 points required.

In dementia screening and assessment, although we did not achieve the 90% target each
month in Quarter 4, the trajectory shows a pattern of improvement since they began in the
summer with a slight dip in February for assessment.

The Nutritional CQUIN scores dipped in the second half of the year and work is on-going to
improve compliance through additional training. In contrast, the patient survey result shows
improved compliance with patients receiving assistance to eat if they required this.

End of life care training was on trajectory with the expectation that numbers trained would
meet the year end expected level.
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In the CQUIN report that follows, details are reported for topics that have not been mentioned so
far, or reported in less detail elsewhere in the Quality Account.
CQUIN 2012-13 report
Patient Safety Thermometer
In 2012-13 this new nationally mandated CQUIN was implemented across the organisation. It
requires data to be collected on every inpatient in the hospital on one day each month. Safety topics
in the ‘thermometer’ include recording information about pressure ulcers, falls, venous
thromboembolism and catheter-related urinary tract infections. The ‘thermometer’ is a national
electronic database that aggregates reports from the hundreds of hospitals using the tool and enables
comparison of results against national averages.
We set a programme for rolling out the ‘thermometer’ across the hospital by the end of July and have
been reporting 100% of ward areas each month since August. This meets the CQUIN target for 2012.
The average rate of patients assessed as ‘harm free’ in the six months since August is above 92%.
This is in line with the national average reported in September 2012 of 91.3%.
In 2013-14 monthly reporting will continue with a trajectory to reduce the total level of harms related to
pressure ulcers in particular agreed with our commissioners as part of the year’s CQUIN contract and
as part of a Somerset-wide approach to reducing the incidence of pressure ulcers in the community
as well as in hospitals.
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Anti-psychotics Prescribing
This CQUIN aimed to ensure safer prescribing and management of patients with behaviour and
symptoms associated with dementia. The objectives include ensuring prescribing is appropriate for
the patient and reviewed within the correct timescales including timely communication with the
patient’s GP about review. Data collection is on-going in this audit and results will be reported once
they are available.
High Impact Innovations
Three topics were identified in the CQUINs framework two of which aim to reduce the need for face to
face contacts between patients and doctors and one that supports best practice for patients
undergoing high risk surgery. Progress in all three topics is expected to continue through 2013-14.
Use of Assistive Technology
Assistive technology (equipment that monitors a range of parameters such as blood pressure, weight,
heart rate etc) placed in patients’ homes can help them to reduce the need for admission to hospital.
This is undertaken through remote monitoring by a care manager in the community. Our initial
engagement this year has been via the COPD team advising community matrons about patients with
chronic breathing problems who may benefit from remote monitoring, helping the patients to manage
their own conditions and reporting signs and symptoms earlier that indicate potential deterioration in
their condition. This enables early interventions to be made. It is anticipated that the COPD nursing
team may take on a role as care managers in 2013-14.
Advice and Guidance
For many patients a GP referral to see a hospital doctor can be better managed by use of technology
at the hospital to better support patients at home, such as providing advice and guidance by
telephone, fax or email. The CQUIN for this recommended testing the process to assess the impact.
Across the three specialties involved, 26% of referrals were managed successfully in this way.
Patient Safety in high risk surgery
This innovation relates to monitoring a patient’s fluid balance during and immediately after surgery
using a dedicated monitor. We have developed a system for recording the frequency with which
patients are monitored in this way and identified the relevant conditions where this is appropriate.
Improved Planning for End of Life Care
The focus for this topic related to staff training in advanced care planning and an audit of use of the
care pathway, patients dying in their place of choice and survey of carers’ experiences including the
provision of written information after death and communication with GP/Primary Health Care Team
after death. Doctors, nurses and health care assistants from 10 key areas where deaths were more
likely to occur, were targeted for training this year. We aimed to have trained 448 staff by end of
March 2013 which represents 90% of those grades of staff in these areas. By the end of February
2013, 355 of the 448 had been trained with a plan to train 140 more in March 2013 which will take us
above target.
New for 2013-14 are topics agreed with our commissioners, some of which are national
requirements and all of which are intended to drive improvements in patient care. All topics will be
subject to incentive payments depending on the level of achievement. Topics include:
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
Implementing the Friends and Family Test

Harm reductions and incidence as measured by the patient safety thermometer

Improvements in dementia care

Risk assessing for and understanding venous thrombotic events (blood clots)

Improving communications about outpatient consultations and results and with GPs

End of life care actions

Care of patients with diabetes to reduce the incidence of foot surgery

Management of patients with problems related to chemotherapy

Reducing the number of healthcare acquired pressure ulcers

Developing a care pathway for the frail elderly.
Results from these topics will be reported in next year’s quality account.
Patient Safety
Safe discharge from hospital
The transition between hospital and home is an area of care for which a dedicated Discharge Action
Group leads and monitors how we are doing. It is essential to ensure discussions are held with
patients, and with family or carers where appropriate, about discharge to promote a safe transition
and that these discussions are recorded. Evidence that discharge has been discussed with the
patients and/or relatives has remained around 80% for the year, as measured by monthly review of
notes, whilst in the monthly patient survey it has been between 60-70%.
Data source: Nursing & Midwifery Metrics
To encourage discharge home earlier in the day and at weekends once patients are fit, all wards
have targets for percentages of weekend discharges and discharges before 2.00pm. Most wards are
meeting these targets on a regular basis.
The focus this year from the discharge group has been on improving discharge to community
hospitals, nursing and residential homes. A nursing home manager now attends the discharge group
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so that actions and issues can be worked on jointly and representatives from the Trust attend care
home manager meetings to work with them on improving processes.
There is anxiety about how the continued changes within adult social services will impact on the
Trust’s ability to access appropriate social and on-going nursing care and we are working with the
commissioners to ensure our views are represented on these issues.
All patients with a length of stay of over 10 days are reviewed by senior nurses and social workers on
a weekly basis to ensure that any blockages to discharge are identified and dealt with.
The focus for the coming year will continue in these two areas with more work on readmissions to
ensure that discharge practices are not affecting this. Complaints about discharge issues as well as
comments from primary care, social services and care homes are also now monitored to ensure that
problems are not developing.
Right medicine at the right time
Medicines reconciliation on admission
Ensuring that patients continue to receive the medicine they take at home whilst in hospital is
extremely important when patients have pre-existing medical conditions. We continue to ensure that
such medication is logged and understood as early as possible when they are admitted to hospital.
Our pharmacy has systems to achieve this for all patients.
Local Target:
95% compliance
Actual 2008-09
Actual 2009-10
Actual 2010-11
Actual 2011–12
90% compliance
94% compliance
92% compliance
93% compliance
Actual 2012-13 95% compliance
Medicines before surgery
Patients often need to fast in the period before surgery and some medications need to be withheld;
however it is important to ensure that necessary medicines are not withheld inappropriately. A project
to ensure patients receive appropriate medications before surgery concluded in 2012-13 having
achieved a 69% reduction in the number patients with medicines inappropriately withheld. The current
level of assurance identifies missed doses as an occasional event. The following chart shows the
number of patients audited and with one or more missed doses of prescribed medication due to
inappropriate clinical reason in the pre-operative period on five surgical wards from August 2010 –
February 2013.
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Data Source: Pharmacy Audit records
Prescribed Medicines
It is also important that patients on all wards receive their medications as prescribed. Each month we
review prescription charts on every ward to check that a range of standards are met that include
identifying and understanding the reasons for any omitted drugs. Our target is 95% compliance and
overall we have consistently bettered this level over the year.
Antimicrobial prescribing
Safe and effective use of antibiotics is essential to ensure appropriate management of patients with
infection and to minimise bacterial resistance to antibiotics. Since 2004, a multi-professional
antimicrobial prescribing group has led and monitored actions related to safe and effective
prescribing. Involving Consultants from every Directorate, dedicated antimicrobial pharmacists,
nurses and the infection prevention team, a range of activities are undertaken which contribute to
successful ‘antimicrobial stewardship’.
In April 2011 the group launched an antimicrobial prescribing ‘bundle’ of actions focusing on
prescribing documentation and compliance with guidelines. Both aspects are monitored monthly and
results are reported to the Directorate leads. Compliance with prescribing guidelines is consistently
above 90% and documentation compliance has almost doubled to 70%. In addition there are four
antimicrobial ward rounds each week across medical and surgical wards supporting the care of
patients treated with broad spectrum antibiotics. Each month 150 – 200 prescriptions are reviewed;
results consistently show more than 90% patients have a clinical need for the antibiotics prescribed.
Where this need is not identified, the antibiotic is stopped and teaching is provided to the prescriber.
These achievements are shown in the next graph.
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Medicines Information
To help patients before coming into and at the point of leaving hospital, this year we introduced a
leaflet about medicines. It answers commonly asked questions and provides advice about bringing
medicines to hospital, how to get more and what can be expected regarding taking medications
home. It also tells patients how to get more medicines information once they have left hospital. The
National Patient Survey 2012 result identified a reduction in the percentage of patients reporting not
being given completely clear written/printed information about medicines at discharge shows we have
improved, decreasing from 34% in 2011 down to 25% on 2012 which is broadly in line with the
national average of 26%. In the national survey we also improved our score for patients reporting
being told about medication side-effects to watch for when they went home, going up from 44 in 2011
to 46.4 in 2012.
Control of infection:
Hand washing
A key component in the reduction of infection is thorough hand hygiene by our clinical staff. This is an
important issue for the Trust and all our patients. Patients are encouraged to challenge staff if they
have concerns and they also will report this through our Patient Advice and Liaison Service. It is an
area that we will continue to focus on and monitor.
Monthly Hand Hygiene compliance audits are carried out by all areas. In addition in 2012-13, the
infection control nurses undertook hand hygiene validation audits against which we check how well
the data is collected. Results are fed back to matrons and the wards.
Local Target: 95% compliance
Actual 2009-10: 88% compliance
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Actual 2010-11: 96% compliance
Actual 2011-12: 97% compliance
Actual 2012-13: 98% compliance
Norovirus
Noroviruses are a group of viruses which are the most common cause of infective gastroenteritis in
the UK, are highly infectious and cause regular outbreaks in the community and hospitals. Norovirus
outbreaks can occur at any time of year and are more common in the winter months with hospital
outbreaks often leading to ward closure and major disruption in hospital activity.
Between October 2012 and April 2013 there were 15 norovirus outbreaks in the Trust resulting in 10
whole ward closures and 5 bay closures. A total of 119 patients were reported as affected. Overall
632 bed days were lost. This was a marked decrease in the number of closures in the year 2011/12
when there 31 whole ward closures, 3 bay closures and a total of 384 patients affected.
Outbreaks were managed robustly in line with the Trust’s Management of Norovirus policy and the
Guidelines for the management of norovirus outbreaks in acute and community and social care
settings’ (DH Norovirus Working Party December 2011).
Clinical Effectiveness
Hospital Standardised Mortality Ratio (HSMR)
HSMR is a national measure which compares the actual number of deaths occurring in a hospital
against those in other hospitals with similar patient admissions. A value of 100 represents a match of
actual deaths compared to what would be expected; a value below 100 indicates better performance
(fewer deaths than expected). Death rates inevitably fluctuate over the short term, which means that
observing them over longer periods of time (6-12 months) provides a better perspective of genuine
trends.
Mortality rates are also influenced by other factors than care quality (population demographics, hospital
case mix, palliative care arrangements), which makes interpreting and comparing them difficult.
Nevertheless, they are widely used and such we scrutinise them to provide early warning clues about
problems in our Trust.
Trust results - discussion
The following graph illustrates our quarterly overall HSMR (preceding 12 month period) over the last
three years. Our value has consistently been below 100 on average. This provides a relatively high
degree of confidence that our overall mortality performance compares well to the rest of the country, and
that we are maintaining this standard consistently. It should be noted, though, that small variations are
not necessarily accurate reflections of changes in our standard of care – these are statistical
representations, with certain inherent errors, and are most valuable to detect major deviations or trends.
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Data source: Dr Foster
NB 100 is the HSMR average, rating lower than 100 represents better than average
Apart from providing overall mortality rates, it is possible to extract more specific mortality rates, for
instance for certain diagnoses, procedures and admission times. It has been noted that patients
admitted over weekends have recently appeared to have a relatively higher mortality rate than those
admitted during the week. As there is no immediately obvious explanation to this, a review of notes of all
patients that died following a weekend admission from September to December 2012 is underway.
Data source: Dr Foster
Detection of deviations
Performance indicators such as SHMI and HSMR, including their ability to examine specific subgroups
of patients, are useful to provide early warning of problems in patient care. For this reason, the Trust
regularly monitors our outcomes through tools such as Dr Foster and the NHS Information Centre,
providing assurance. Where outcomes appear to be deviating, this allows verification of validity of the
result, and an early opportunity to take corrective action.
For the period February 2012 to January 2013 we had the third lowest HSMR of our peer group of
hospitals against which we benchmark data. In this period our HSMR was 95.9. The best performing
Trust had a rate of 79.8 and the poorest performer had a rate of 104.0.
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Data source: Dr Foster
Average length of stay
Monitoring the average length of stay for our patients is important in helping patients know how long
they may be in hospital and for the Trust to determine requirements in terms of the number of beds
needed and the requirements of differing specialties. Reports on average length of stay are monitored in
regular Board reports and at a lower level by each Directorate. It is usual to see a higher length of stay
over the winter months from November to March during which period we open additional beds in a
‘winter ward’ to manage the increased demand especially among older patients.
Days
The average length of stay for all patients discharged from the hospital (excluding day cases) in 2012-13
was 3.7 days, as indicated in the flowing graph.
Data source: Dr Foster
There is a difference in length of stay between elective (planned) admissions and patients that present
as emergencies. The following graph shows that in 2012-13, for all cases, the length of stay for patients
admitted as elective cases was lower than that of emergencies. We would expect this as most elective
cases have very predictable length of stay whereas emergency cases are often more complex and need
longer to treat. The average length of stay for elective admissions was 2.6 days compared to 3.9 days
for emergency patients.
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Average length of stay - Elective vs emergency admission
4
Days
3
2
1
0
April 2012
May 2012
June 2012
July 2012
August
2012
September
2012
October
2012
November
2012
December
2012
January
2013
February
2013
March 2013
Data source: Inpatient Service Department
Days
Among the emergency patient group, the average length of stay for medical patients was 5.3 days and
4.6 days for surgical patients, as shown in the following graph. The Trust uses length of stay as well as
admission and discharge information to predict its workload on a daily basis.
Data source: Inpatient Service Department
30 day Readmissions
The readmission rate for patients is an important marker in ensuring patients are safely discharge and
that readmissions for the same condition are minimised. In 2012-13 the unplanned 30 day readmission
rate was 5.9%. The following graph shows several months of the most recent data suggesting the 30
day unplanned readmission rate has deteriorated. As stated elsewhere in this report, there will be a
focus in 2013-14 on understanding readmissions to enable us to identify ways to reduce the numbers
appropriately.
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Data source: Inpatient Service Department
Note: there is a known data quality issue being addressed which will overstate the true level of
admissions.
Patient Experience
Patient Experience Surveys
Listening to patients views and actively seeking feedback is essential to patient-centred care. Taunton
and Somerset NHS Foundation Trust has a ‘multi-layered’ feedback strategy. This is supported by a
patient-centred culture and the values of the hospital. The principles that underpin the strategy are;







Measurement should be continuous and the results available real time.
All patients should have the opportunity to give feedback
Feedback from relatives and carers is encouraged.
Accessible to all, patients will have choice on how they feedback, with a wide range of methods
and support available for patients and families to give feedback.
Feedback and measurement of experience is core business and a standard part of service
delivery
Feedback is used for improvement and is a core element of the Improvement Network.
The equal value of quantitative and qualitative feedback
Specialty/Ward/Department feedback
This is feedback gained by our teams about the service they provide. Giving teams the tools and support
to gain feedback and drive service improvements through the eyes of patients. The Improvement Network
has developed a tool kit to support this, examples of approaches include patient shadowing, patient
stories, surveys (a variety of methods such as telephone, paper surveys, face to face interviewing, apps,
and web/intranet online feedback), feedback cards and focus groups.
Trust wide rolling programme of real time survey feedback
This includes all of the hospital with surveys covering a representative and meaningful sample size.
These are more in depth surveys asking for feedback on what are known to matter most to patients.
These areas broadly relate to consistency and coordination of care, respect and dignity, involvement,
staff, cleanliness and environment, food and pain control. These surveys are available in a number of
formats, volunteer supported interviews, electronic survey’s whilst in the hospital and internet accessible
surveys.
Friends and Family Test
From April 2013 all adult in-patients and patients attending Accident and Emergency will have the
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opportunity to give us feedback on how likely they are to recommend Musgrove to friends and family.
From October 2013 this will include maternity with further roll out in line with national guidance. A range of
methods will be available to allow patients to take up this opportunity at the point of discharge. In January
2013 we introduced the nationally-approved wording by asking patients if they would be likely to
recommend the hospital to family and friends. The results were 73.5% of patients said they were
extremely likely to recommend the hospital to friends or family with 94.4% of patients either extremely
likely or likely to recommend the hospital. Participation in National surveys
As a hospital we participate in national surveys (In-Patient, Out-Patient, A&E, Maternity, and Cancer).
These surveys give us the opportunity to benchmark and particularly the national in-patient survey is
aligned to the CQUIN.
The results of the national inpatient survey 2012 were published in April 2013. For 23 aspects of care we
are significantly better than the average results when compared to 73 Trusts nationwide. These areas
included:








Admission organization and getting to a bed
Hospital food;
Important aspects of care such as involvement and emotional support;
Privacy;
Getting clear information from doctors and nurses
Sufficient nurses on duty;
Discharge focused questions relating to involvement and information; and
Overall rating of care and recommendation of hospital.
How was it for you – Complaints Feedback
Learning from complaints and concerns provides really important feedback. Every complaint and concern
is looked at the see what we can learn and improve as a result.
Since 2011 we have been working in partnership with the Patients Association. Everyone who has made
a formal complaint is sent a survey to ask them about their experience of raising a complaint in our
hospital. The Patients Association provides a level of independence supporting people to tell us what they
think.
Patient and Public Involvement (PPI)
The hospital has a patient Experience Committee which is chaired by a patient. This group has
membership from the local HealthWatch and the CCG. The annual programme of work for patient
experience includes working with key partners and local groups such as the Taunton Deaf Club and
Compass Disability. We also involve and seek feedback via our trust membership which as at January
2013 there are 10,851 public and 3,412 staff members.
The Hospital has a growing number of active volunteers who contribute hugely to the hospital. Our survey
volunteers and Musgrove Partners particularly help us with implementing our PPI and patient feedback
work. Musgrove Partners help with our recruitment and selection of staff, are members of key committees
across the hospital, facilitate focus groups to name only a few of their activities. The Trust Governors
Patient Care Group reviews feedback from patients/relatives and adds to that a regular report from the
Governors on feedback they have gained from the local community called “It’s Good to Know”.
Letters/Comments on national feedback sites
The hospital receives a huge number of thank you letters and comments which are made on the Hospital
internet or via e-mail. Each of these comments is reviewed, forwarded to the appropriate teams / clinical
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areas for action as appropriate and responded to. Comments are also made via national on-line services
such as NHS Choices and Patient Opinion, from February the PALs team will include the review and
response to these in their responsibilities.
Privacy and Dignity
Our patients rightly expect that during their stay in hospital they are treated with dignity and respect. This
is a question that we specifically ask our in our monthly survey of inpatients. We aim for 95% of those
surveyed to feel that they have been treated with dignity and respect.
Percentage (and number) of patients surveyed
who feel they are treated with dignity and respect
Always
Most of the time
No
2009-10
(1,602)
88%
10%
2%
2010-11
(1,499)
93%
6%
0%
2011-12
(1,846)
89%
9%
2%
2012-13
(1,798)
93%
6%
1%
One important aspect is the provision of single sex accommodation, and not having to share sleeping or
washing areas with patients of the opposite sex. This should only happen when it is clinically necessary –
for example, when patients need specialist equipment in critical care or high dependency areas. The
situation is continually monitored and reported to the Trust Board in the Quality Report.
Results from the National Inpatient Survey taken from patients in hospital during July and August
identified that we were worse than average regarding sharing of sleeping areas and bathrooms compared
with other hospitals. Our inpatient survey from July and August 2012 also showed patients from 8 wards
reporting an increase in people reporting some sharing although there were no actual mixes of patients
within sleeping areas at the time. All our wards are compliant with the environmental requirements and we
monitor the situation weekly to ensure any mixing of sexes in sleeping accommodation is for clinically
justified reasons only.
As our local population will know, work has started on the Jubilee Building which will replace five of our
old surgical wards with 112 single en-suite rooms. We look forward to welcoming our first patient there
towards the end of the year.
Patient Care Rounds
Patient care rounds have not be reported before as they form a change to the way care has been
conducted beginning in 2011.
Routinely and regularly attending to patients is an important part of nursing care. The introduction of twohourly formal ‘rounding’ with the intention to provide specific aspects of care was successfully tested in
the Medical Assessment Unit in 2011 and completed as a roll out across all the hospital wards by July
2012. Implementation was supported by staff training and a simple means of documenting care given and
a measurement strategy to enable us to identify if improvements are made.
One important outcome of regular care-rounding should be that call bells are answered promptly. Patients
are asked about this in our monthly survey. The following graph shows improvement overall from 64%
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towards 80% with sustained improvement from October 2012 to February 2013. The dip seen in March
corresponds with an extraordinary rise in the number of emergency admissions when several additional
ward areas were opened to manage the demand that created challenges to the numbers and deployment
of permanent and temporary staff.
Percentage of patients who report that they usually receive help right away/within 1-2 minutes after using call button
(All who had used the call button)
100.0%
80.0%
60.0%
40.0%
April 2012
May 2012
June 2012
July 2012
August
2012
September
2012
October
2012
November
2012
December
2012
January
2013
February
2013
Data Source: Monthly Inpatient Survey
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March
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NATIONAL TARGETS AND REGULATORY REQUIRMENTS
Key Targets
Threshold
2008/09 2009/10 2010/11 2011/12 2012/13
Cancer: Decision to Treat in
31 Days
96%
-
96.9%
99.6%
99.4%
98.4%
Maximum waiting time of 31
days
for
subsequent
treatments where subsequent
treatment is surgery
94%
-
95.3%
99.7%
97.1%
96.7%
Maximum waiting time of 31
days
for
subsequent
treatments where subsequent
treatment is Drugs
98%
-
99.0%
100%
100%
99.9%
Maximum waiting time of 31
days
for
subsequent
treatment where subsequent
treatment is Radiotherapy
94%
-
-
100%
100%
98.5%
Cancer:
Referral
to
Treatment in 62 Days.
Measured for all cancers
from date referral is made to
Trust to the date of the first
definitive treatment *
85%
-
91.7%
94.7%
90.7%
88.6%
Maximum two month wait
referral
from
an
NHS
Screening
service
to
treatment for all cancers
90%
-
93.4%
98.8%
100%
95.2%
1
8
3
1
1
0
100%
-
100%
100%
88.8%
89.9%
44
55
48
73
37
19
90%
92%
87.8%
91.5%
91.8%
92.2%
95%
99%
97.6%
97.1%
97.25%
96.5%
MRSA
Screening of all elective
inpatients for MRSA (ratio of
swabs)
C Difficile
reduction
year on year
18
Week
Referral
to
Treatment: Admitted Patients
18
Week
Treatment:
Patients
Referral
to
Non-Admitted
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Key Targets
Threshold
Making the most of Musgrove
2008/09 2009/10 2010/11 2011/12 2012/13
Maximum time of 18 weeks
from point of referral to
treatment in aggregate –
patients on an incomplete
pathway
92%
-
-
-
-
93.3%
Sexual Health: Access to GU
Clinic (48 hours)
100%
100%
100%
100%
100%
100%
A&E Waiting Times: 4 hours
to admission, transfer or
discharge
98%
98.3%
98.4%
97.1%
95.5%
96.34%
Cancelled Operation: Offered
another binding date within
28 days
95%
99%
93.6%
93.5%
99.1%
98.8%
Maximum Waiting Times:
Revascularisation (No. >3
months)
0
0
0
0
0
0
93%
-
96.5%
96%
94.8%
94.9%
Cancer: Referral to first
appointment (14 days) –
Symptomatic
Breast
Referrals – From January
2010
93%
-
98%
98.8%
96.7%
Maximum Waiting Times:
Rapid Access Chest Pain
Clinics (14 days)
100%
100%
100%
99.6%
100%
100%
Delayed Transfers of Care –
maximum level
3.5%
1.4%
3.2%
4.9%
3.7%
2.6%
% Stroke patients spending
90% or more of their time on
a Stroke Unit
80%
75.7%
41.8%
68%
83%
85%
% High Risk TIA patients
treated in 24 hours
60%
-
23%
59%
80%
76%
Cancer: Referral to
appointment (14 days)
first
95.8%
Q4 only
*62 day cancer wait: the indicator is expressed as a percentage of patients receiving their first definitive
treatment for cancer within 62 days of an urgent GP referral for suspected cancer. An urgent GP referral is
one which has a two week wait from the date that the referral is received to first being seen by a consultant.
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Annex One
A draft copy of our Quality Account was sent to:
 Somerset NHS Clinical Commissioning Group
 Bristol Healthwatch
 Oversight and Scrutiny Committee, Somerset County Council
The following responses were received:
Clinical Commissioning Group report
As lead commissioner, Somerset Clinical Commissioning Group (and previously NHS Somerset)
has monitored the safety, effectiveness and patient experience of health services at Taunton and
Somerset NHS Foundation Trust during 2012/13. The Trust’s engagement in the quality contract
monitoring process provides the basis for commissioners to comment on the quality account
including performance against quality improvement priorities and the quality of the data included.
We have reviewed the achievements against the National Performance Indicators as outlined in
the account and can confirm that the reported position is accurate.
We have reviewed the identified Quality Improvement priorities for inclusion in the Quality
Accounts for 2012 /13 and would comment as follows:
Quality - The Patient at the Heart of Everything We Do
Ensuring that we put patients first in all that we do is essential for patients to receive care that
meets their needs, and is provided by caring and compassionate staff. The publication of the
Francis report has emphasised that the NHS must put patients at the centre and ensure that
fundamental standards of care are met. The CCG acknowledges the strong ethos within the Trust
for stakeholder and patient engagement and recognises the work the Trust has undertaken to
strengthen arrangements for improved patient experience through the use of real time patient
surveys, improved experience for people with a learning disability and focus on the needs of
people with dementia and the environment of care. The CCG can confirm that the Trust regularly
reviews the quality and safety of its services using a variety of quality indicators and these are
reported to the CCG at the quarterly clinical quality review meetings.
Patient Safety

Sustaining the reduction of hospital acquired infections
Somerset CCG confirms the data for healthcare acquired infections for 2012 /13 as correct. The
Trust achieved the national target of no more than 44 cases of C difficile acquired after 72 hours
of admission, with an overall year end position of 19 cases. This is a considerable achievement
and the Trust is commended for the focus given to the reduction of cases. The Trust is also
commended for achieving the national target of no more than one case of MRSA bloodstream
infection, with no cases reported during the year. Somerset CCG notes evidence of continued
focus on reducing healthcare associated infections which includes a focus on reduction of surgical
site infections and catheter associated urinary tract infections, as well as learning from outbreaks
and incidents to improve care for patients.

Improving patient safety by reducing falls and pressure ulcers.
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The Trust has implemented a wide range of interventions to reduce and mitigate the risk of
patients falling in line with local targets. The CCG confirms the achievement of the Trust in both
the reducing the rate of falls to patients and falls that cause harm and the assurance provided by
monthly reporting on use of the falls care bundle Considerable focus has been given to reducing
the number of patients falling, as well as those falls which result in harm. This area of patient
safety will continue to be subject to ongoing scrutiny via the Clinical Quality Review process to
ensure that the Trust continues to focus on reducing the number of patients who fall and who are
harmed as a result of falls.
It is pleasing to see the improvements achieved and the actions required to improve practice
included in the report resulting from serious untoward incidents. Ensuring lessons are learned
from serious untoward incidents, and that these are embedded across the Trust, provides
evidence of a strong safety culture and focus on improvement.
The increase in rate of reported pressure ulcers (grade 2 or above) from 1.14 per 1000 bed days
in 11/12 to 1.33 per 1000 bed days in 12/13 is acknowledged. Somerset CCG confirms the
position that, whilst improvements have been made in identifying, reporting and investigating
hospital acquired pressure ulcers, the reduction target was not met. The Trust has participated as
a member of the Somerset Harm Free Care Collaborative to develop a consistent approach to
reducing pressure ulcers through use evidenced based tools.
In recognition of the need for improved focus and reduction of incidence, work in the Trust will
continue to reduce pressure ulcer development in patients in receipt of healthcare services and to
achieve a zero tolerance culture to the development of pressure ulcers. The Trust has been set a
challenging target of 40% reduction in avoidable hospital acquired cases for 13/14 in light of this
position.

Ensuring patients receive adequate and nourishing food
Somerset CCG notes the improvements made during 2012/13 from the Trust’s local inpatient
survey data reporting help and assistance for patients with feeding. The CCG endorses the
Trust’s intention to continue with a focus on ensuring patients receive an appropriate level of
hydration and nutrition and will continue to monitor performance against this area during the
coming year.

Caring for Patients with dementia
The Trust has gained significant momentum with improvements in the early identification and
diagnosis of patients with dementia and has demonstrated achievement of Level 2 standards of
the South West Dementia Partnership Strategy in accordance with local CQUIN requirements.
Whilst the target of 90% was not achieved by year end to support early diagnosis, the Trust has
demonstrated the greatest distance of travel against these indicators than comparators from
across the South West region.
Never Events
The Trust reported one Never Event of wrong site surgery that involved the services of another
NHS provider. The Trust instigated the ‘Being Open’ policy with the patient concerned and the
final investigation report has been shared with the patient so that they could both contribute and
understand the changes made to ensure that this did not happen again. A key area of work going
forward was to improve arrangements for the timeliness of specimen and test results to be
available to multi-disciplinary teams for review and to ensure that all staff receive induction into
their role including locum staff. The process of investigation and review with both organisations
involved, allowed for organisational learning and improvements in the management of the patient
pathway to reduce the likelihood of a similar occurrence.
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Serious Incidents requiring Investigation (SIRIs)
The Trust reports all SIRIs requiring investigation to Somerset CCG and the progress of the
investigation and the implementation of the lessons learned is monitored by the CCG. During
2012 – 13 the termination of pregnancy service provided by the Trust was inspected by the Care
Quality Commission and found to be non-compliant with ensuring two doctors signed the consent
form for patients requiring a termination. The Trust undertook a robust investigation which
indicated that the pathway and approach in place was designed around meeting the needs of the
patients. The Trust has fully implemented the recommendations of the investigation and ensured
that the pathway is now compliant.
Clinical Effectiveness

Improving how well we communicate
The Trust embarked on a local programme of improvement in communication systems including
Complaints and PALS and issue of discharge summaries. A reduction in the number of formal
complaints is noted across the year, although an increase in Quarter 3 was noted and discussed
via Clinical Quality Review meetings.
A local programme of improvement for Administration Excellence was launched during the year
and changes to processes, including the development of standard operating procedures, to
ensure consistency across the Trust, have been presented to the CCG as evidence of
improvements.

Clinical audit programme
The Trust has participated in a broad number of national audit programmes which provide
assurance of the quality of treatment and care, and the outcomes of care for patients. It is positive
to see the actions being taken in response to the outcomes of participation in national audits and,
in particular, the actions taken for cancer care.
The Trust’s achievement of a consistently low HSMR across a seven day week continues to
reflect the impact of introducing consultant working at weekends and increased availability of the
Critical Care Outreach Team and should be noted as evidence of good practice.
Patient Experience
Somerset CCG notes the improvements made during 2012 –13 in the timeliness of the provision
of written discharge summaries to GPs and the number of patients who receive copies of letters
sent by hospital doctors to GPs. The CCG will continue to monitor these areas and is working with
the Trust to audit the quality of discharge summaries in 2013 – 14. Communication about the care
and treatment for patients in hospital and provision of information to relatives is important in
ensuring both the continuity of care for patients as well as safe treatment.
The performance of the Trust in the annual patient survey for 2012 – 13 indicates that in general
the performance of the Trust compares well to other Trusts and to previous year’s performance.
A number of patients were concerned about sharing bathrooms with patients of the opposite sex.
On further investigation this relates to wards where there is only one assisted bathroom but there
are single sex showers and to clinical areas where patients receive one to one care at times when
they need close observation. Areas where the Trust did not perform so well include noise at
night, being told about side effects from medicines and danger signals to watch for after going
home. These will be areas for focus in 2013 – 14.
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Improvements in the provision of clinical correspondence for patients and the administrative
systems during the year has been a key focus for the Trust and the CCG has monitored the
reduction in the number of PALS enquiries and complaints in this area.
The CCG confirms the proportion of staff reporting in the annual staff survey that they would
recommend the hospital to their friends and family was 74%. This provides a measure of the
confidence of the staff in the care provided in the hospital. The Trust is well placed to start
reporting against the Friends and Family Test in 2013 and to publish these results for patients and
the public to review the recommendations from people using the services at Musgrove Park.
Data Quality
The Trust has continued to make progress in improving data quality. It is important for the Trust to
demonstrate the quality of care provided and for this to be benchmarked against other NHS
providers. With increasing patient choice the provision of high quality data on the effectiveness
and safety of the care provided to patients at Musgrove Park Hospital will be important for
patients who choose to have their treatment at the hospital.
Quality Improvement Priorities for 2013/14
Somerset CCG supports the quality improvement priorities identified by the Trust for the coming
year. In the light of the publication of the Francis report and the continued focus of the Trust on
both reducing harm from healthcare to patients, improving the experience of patients of
healthcare and ensuring that older people with dementia receive care from staff who have the
skills and expertise to care for this vulnerable group of patients is important.
A number of these priorities have been included in the Commissioning Quality and Innovation
(CQUIN) framework that we have agreed with the Trust as set out below:
 Risk assessment and prophylaxis for VTE (blood clots)
 Friends and Family Test
 Use of the Patient Safety Thermometer
 Identification and early diagnosis of dementia
 Improvement in End of Life care
 Administration of antibiotics in neutropenia
 Provision of test results following outpatient appointments
 Improvement in the management of diabetes foot care
 Development of a Frail Elderly Care pathway
 Reduction in incidence of hospital acquired pressure ulcers.
We can confirm that the Quality Account meets national requirements in respect of content,
provides a balanced view of the Trusts’ achievements and as such is an accurate reflection of the
quality of services provided. Taunton and Somerset has made significant achievements in
improving the quality of the services provided during 2013 – 14 and the number of national
awards for safe care is additional assurance of this position.
We look forward to continuing to work with Taunton and Somerset NHS Foundation Trust during
2013/14 to improve the safety, clinical effectiveness and patient experience of the services
provided by the Trust.
Please contact me at the above address if you wish to discuss any of the above comments
further.
Yours sincerely
Lucy Watson, Director of Quality and Patient Safety
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Healthwatch Report
“Statement written by Healthwatch on behalf of Somerset Local Involvement Network disbanded
31st March 2013.
Somerset LINk welcomed the opportunity to contribute to the Quality Report prepared by Taunton
and Somerset NHS Foundation Trust. The LINk had a positive and constructive working
relationship with the Trust and with the lead on Quality Accounts at Taunton and Somerset NHS
Foundation Trust and recommended that this relationship is continued.
They recommended that Healthwatch responds to the NHS Quality Accounts (QA) and where
necessary applies pressure to ensure that Quality Account documents are received in good
enough time for Healthwatch to develop a thorough response and that information relevant to the
QA is available, discussed and consulted on with Healthwatch throughout the year.
Healthwatch Somerset began in April 2013, and they are not in a position to provide a
comprehensive response to this year’s Quality Account. They look forward to submitting a
comprehensive response in 2014.”
~~~~~
SCC Oversight and Scrutiny Committee
“Thank you for sending us the Trust’s 2012/13 Quality Report, for comment.
Since the last Quality Report there has, of course, been the Francis Report and we noted in the
local press that TSFT had promptly reacted and commented on its level of its compliance with the
core underlying themes of his recommendations – ‘a structure of clearly understood fundamental
standards’, ‘openness, transparency and candour throughout the system’, ‘compassionate caring
and committed nursing’, ‘strong and patient-centred healthcare leadership’ and ‘accurate, useful
and relevant information’. We continue to recognise that the Trust’s commitment to ‘putting
patients at the heart of everything we do’ suggests we are fortunate in Somerset to have our
largest acute hospital already firmly committed to delivering on the Francis principles. We are also
confident that the Trust has the processes and procedures – and, moreover, the right ethos
shared by its management and staff – to make progress in the small number of areas where it
recognises more can still be done. We look forward to receiving an update from the Trust,
perhaps in early 2014, a year post Francis, on what changes it has made to further improve the
service it provides to Somerset’s residents in compliance with the Report’s recommendations and
in its aspirations for overall NHS service delivery.
As a Scrutiny Committee, we have recommended to the incoming administration that the loss of
the previous Health Scrutiny over the past four years should be addressed. We are confident that,
whichever party takes control next month, this will be actioned, particularly in light of the
authority’s having taken on new Health & Wellbeing powers since the start of this month.
As we looked at your Quality Report from a resident’s perspective, we would make only two
further comments; firstly we would like to congratulate the Trust on the work it has done to reduce
the incidence of the two dominant hospital-acquired infections, MRSA and c.diff, delivering a far
better performance than in many other parts of the country. And secondly – as you have asked for
our suggestions – we would ask you to look further into patient communications. Major retailers
suggest that, as a rule of thumb, for every customer who complains about something there are
probably another 10 who felt moved to complain, but never quite got round to it. Poor patient
communications – mostly relating to appointments and associated communication delays – often
comes up in councillor/resident contacts as an issue and it is a shame to see the perception of the
Trust’s excellent clinical performance occasionally marred by this aspect.
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Finally, we look forward to further, closer, working with the Trust in the coming year. We know we
can rely on your continuing focus on the primacy of patients and their needs.
April 30th 2013”
~~~~~
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Annex Two
Statement of Directors’ Responsibilities in Respect of the Quality Report
The directors are required under the Health Act 2009 and the National Health Service Quality
Accounts Regulations 2010 to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual
quality reports (which incorporate the above legal requirements), and on the arrangements that
foundation trust boards should put in place to support the data quality for the preparation of the
quality report.
In preparing the Quality Report, directors are required to take steps to satisfy themselves that:

The content of the Quality Report meets the requirements set out in the NHS Foundation
Trust Annual Reporting Manual 2012-13.

The content of the Quality Report is not inconsistent with internal and external sources of
information including:
-
Board minutes and papers for the period April 2012 to June 2013;
-
Papers relating to Quality reported to the Board over the period April 2012 to June
2013;
-
Feedback from the commissioners dated 15.05.2013;
-
Feedback from governors dated 07.03.2013;
-
Feedback from Local Healthwatch organisations 17.05.13;
-
Feedback from Somerset County Council 30.3. 2013;
-
The Trust’s complaints report published under regulation 18 of the Local Authority
Social Services and NHS complaints Regulations 2009 (as part of the Trust’s
Governance Schedule, this report will be reviewed at Trust Board in October 2013);
-
The 2012 national patient survey report 16.04.2013;
-
The 2012 national staff survey report 11.03. 2013;
-
The Head of Internal Audit’s annual opinion over the trust’s control environment
dated 18.04.2013;
-
Care Quality Commission (CQC) Quality and Risk Profiles dated 31.03.2013.

The Quality Report presents a balanced picture of the Taunton and Somerset NHS
Foundation Trust’s performance over the period covered.

The performance information reported in the Quality Report is reliable and accurate.

There are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Report, and these controls are subject to review to
confirm they are working effectively in practice.
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The data underpinning the measures of performance reported in the Quality Report is
robust and reliable, conforms to specified data quality standards and prescribed
definitions, is subject to appropriate scrutiny and review, and the Quality Report has been
prepared in accordance with Monitor’s annual reporting guidance (which incorporates the
Quality
Accounts
regulations),
(published
at
www.monitornhsft.gov.uk/annualreportingmanual) as well as the standards to support data quality
for the preparation of the Quality Report (available at www.monitornhsft.gov.uk/annualreportingmanual).
The Directors confirm, to the best of their knowledge and belief that they have complied with the
above requirements in preparing the Quality Report.
By order of the Board
NB: sign and date in any colour ink except black
29 05 13
Date…………………………………………….Chairman
29 05 13
Date…………………………………………… Chief Executive
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Annex Three
Independent Auditor’s Report to the Board of Governors of Taunton and
Somerset NHS Foundation Trust on the Annual Quality Report
We have been engaged by the Council of Governors of Taunton and Somerset NHS Foundation
Trust to perform an independent assurance engagement in respect of Taunton and Somerset
NHS Foundation Trust’s Quality Report for the year ended 31 March 2013 (the ‘Quality Report’)
and specified performance indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2013 in the Quality Report that have been subject to
limited assurance consist of the following national priority indicators as mandated by Monitor:
1. Number of Clostridium difficile infections; and
2. Maximum cancer waiting time of 62 days from urgent GP referral to first treatment for all
cancer.
We refer to these national priority indicators collectively as the “specified indicators”.
Respective responsibilities of the Directors and auditors
The Directors are responsible for the content and the preparation of the Quality Report in
accordance with the assessment criteria referred to in on page 153 (Annex 2) of the Quality
Report (the "Criteria"). The Directors are also responsible for the conformity of their Criteria with
the assessment criteria set out in the NHS Foundation Trust Annual Reporting Manual (“FT
ARM”) issued by the Independent Regulator of NHS Foundation Trusts (“Monitor”).
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether
anything has come to our attention that causes us to believe that:



The Quality Report does not incorporate the matters required to be reported on as
specified in Annex 2 to Chapter 7 of the FT ARM;
The Quality Report is not consistent in all material respects with the sources specified
below; and
The specified indicators have not been prepared in all material respects in accordance
with the Criteria.
We read the Quality Report and consider whether it addresses the content requirements of the FT
ARM, and consider the implications for our report if we become aware of any material omissions.
We read the other information contained in the Quality Report and consider whether it is
materially
inconsistent
with
the
following
documents:





Board minutes for the period April 2012 to the date of signing this limited assurance report
(the period);
Papers relating to Quality reported to the Board over the period April 2012 to the date of
signing this limited assurance report;
Feedback from the Commissioners, Somerset Clinical Commissioning Group, dated
15.05.2013;
Feedback from Governors dated 07.03.2013;
Feedback from local Healthwatch organisations, Bristol Healthwatch, 17.05.2013;
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





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The trust’s complaints report published under regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009;
Feedback from other stakeholders involved in the sign-off of the Quality Report, Somerset
County Council 30.3. 2013;
The 2012 national patient survey dated 16.04.2013;
The 2012 national staff survey dated 11.03. 2013;
Care Quality Commission quality and risk profiles dated 31.03.2013; and
The Head of Internal Audit’s annual opinion over the trust’s control environment dated
18.04.2013.
We consider the implications for our report if we become aware of any apparent misstatements or
material inconsistencies with those documents (collectively, the “documents”). Our
responsibilities do not extend to any other information.
We are in compliance with the applicable independence and competency requirements of the
Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team
comprised assurance practitioners and relevant subject matter experts.
This report, including the conclusion, has been prepared solely for the Council of Governors of
Taunton and Somerset NHS Foundation Trust as a body, to assist the Council of Governors in
reporting Taunton and Somerset NHS Foundation Trust’s quality agenda, performance and
activities. We permit the disclosure of this report within the Annual Report for the year ended 31
March 2013, to enable the Council of Governors to demonstrate they have discharged their
governance responsibilities by commissioning an independent assurance report in connection
with the indicators. To the fullest extent permitted by law, we do not accept or assume
responsibility to anyone other than the Council of Governors as a body and Taunton and
Somerset NHS Foundation Trust for our work or this report save where terms are expressly
agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement in accordance with International Standard on
Assurance Engagements 3000 ‘Assurance Engagements other than Audits or Reviews of
Historical Financial Information’ issued by the International Auditing and Assurance Standards
Board (‘ISAE 3000’). Our limited assurance procedures included:



Evaluating the design and implementation of the key processes and controls for
managing and reporting the indicators
Making enquiries of management
Analytical procedures

Limited testing, on a selective basis, of the data used to calculate the specified indicators
back to supporting documentation.

Comparing the content requirements of the FT ARM to the categories reported in the
Quality Report.

Reading the documents.
A limited assurance engagement is less in scope than a reasonable assurance engagement. The
nature, timing and extent of procedures for gathering sufficient appropriate evidence are
deliberately limited relative to a reasonable assurance engagement.
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Limitations
Non-financial performance information is subject to more inherent limitations than financial
information, given the characteristics of the subject matter and the methods used for determining
such information.
The absence of a significant body of established practice on which to draw allows for the selection
of different but acceptable measurement techniques which can result in materially different
measurements and can impact comparability. The precision of different measurement techniques
may also vary. Furthermore, the nature and methods used to determine such information, as well
as the measurement criteria and the precision thereof, may change over time. It is important to
read the Quality Report in the context of the assessment criteria set out in the FT ARM and the
Directors’ interpretation of the Criteria in Annex 2 of the Quality Report.
The nature, form and content required of Quality Reports are determined by Monitor. This may
result in the omission of information relevant to other users, for example for the purpose of
comparing the results of different NHS Foundation Trusts.
In addition, the scope of our assurance work has not included governance over quality or nonmandated indicators in the Quality Report, which have been determined locally by Taunton and
Somerset NHS Foundation Trust;
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to
believe that for the year ended 31 March 2013,
 The Quality Report does not incorporate the matters required to be reported on as
specified in annex 2 to Chapter 7 of the FT ARM;
 The Quality Report is not consistent in all material respects with the documents specified
above; and
 the specified indicators have not been prepared in all material respects in accordance
with the Criteria.
PricewaterhouseCoopers LLP
Chartered Accountants
Plymouth
29 May 2013
The maintenance and integrity of the Taunton and Somerset’s website is the responsibility of the
directors; the work carried out by the assurance providers does not involve consideration of these
matters and, accordingly, the assurance providers accept no responsibility for any changes that
may have occurred to the reported performance indicators or criteria since they were initially
presented on the website.
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