QUALITY ACCOUNT 2012/13
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CONTENTS
Part One: Statement on Quality from the Chief Executive of Mid Yorkshire
Hospitals NHS Trust on behalf of the Board
1.1 Our vision and values
1.2 Our corporate objectives
1.3 Making it better together
1.4 Nursing and Midwifery Strategy
1.5 Staff survey 2012
1.6 Inpatient survey 2012
Part Two: Priorities for improvement and statements of assurance from the
Board
2.1 Our quality priorities for 2013/14
2.2 Statements of assurance from the Board:
2.2.1 Clinical Audit
2.2.2 Research and Development
2.2.3 CQUIN
2.2.4 Registration and Compliance
2.2.5 National and contractual quality standards
2.2.6 Patient Advice Liaison and Complaints
2.2.7 Data Quality
Part Three: Other Information
3.1 Our quality priorities for 2012/13
3.1.1 HSMR
3.1.2 Safety thermometer
3.1.3 Dementia
3.1.4 HCAI (MRSA, C.Diff)
3.1.5 Outpatient appointment scheduling
Annexes –
1. Comments received on the quality account
2. External audit report
3. Glossary of Terms
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The Quality Account
This is an important document which informs the public about the quality and safety
of the services provided by our Trust. All NHS organisations are required to publish
an annual quality report and account which evidences the quality of services
provided and demonstrates a genuine commitment to quality improvement.
This document complies with the Trust’s statutory duties under the Health and Social
Care Act 2012 and Department of Health Guidance for Quality Accounts for 2012/13.
The account provides information on our;
•
achievements over the last year
•
a review of the quality of services and statements of assurance from the
Board
•
priorities for quality improvement in 2013/14
We hope this report provides information for local people, patients and their families,
stakeholders and our staff to enable them to be assured that our number one priority
is to provide high quality services.
The Trust is grateful to our key stakeholders for the comments received. It is
pleasing that the content also meets with auditors approval. Comments from all
stakeholders will be considered when producing the report for 2013/14
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Part One: Statement on Quality from the Chief Executive of Mid Yorkshire
Hospitals NHS Trust on behalf of the Board
‘Ensuring quality is at the heart of everything we do’.
On behalf of the Board, I am pleased to introduce my second Quality Account as
Interim Chief Executive of The Mid Yorkshire Hospitals NHS Trust. This report is
intended to complement our full Annual Report and summarises our performance
against selected quality indicators. Members of the Local Involvement Networks and
the Overview and Scrutiny Committees have again worked with us, to challenge and
review our performance against these quality indicators throughout 2012/13 and for
this I am grateful.
During 2012/13 the Trust has made considerable progress in providing assurance to
our patients and local people about the safety and quality of our services. A key
concern nationally following publication of the second Francis Report in February
2013 is mortality rates and this is an important area where we have improved our
performance so that they are within the national average. We have also made
considerable improvements against key performance targets, such as the four hour
emergency care standard and 18 weeks referral to treatment, despite experiencing
high levels of demand for our services. Although our progress in these areas is
essential, what I hope this Quality Account demonstrates is that we have also
improved the experience of our patients, whether that it is in being seen quickly,
receiving the safest possible treatment or in their interactions with any of our staff.
The improvements we have made have resulted in increased confidence in the Trust
and our services. It has been important to establish that having set out our priorities
for improving quality and safety, there is a strong commitment across the
organisation to deliver and ensure improvement is sustainable. In this context we
have worked hard with our clinical commissioners and the Care Quality Commission
during 2012/13 to develop a mutual understanding of the quality priorities and
develop a much more constructive relationship with both key stakeholders. I am
pleased to say that we are now working in partnership with the Care Quality
Commission on the improvement agenda which has resulted in a substantial
reduction in compliance actions during the year to just one action for which the Trust
has submitted an application.
As well as the increased confidence in the Trust from regulators and stakeholders I
hope that the commitment we have made to quality and safety over the last 12
months has also resulted in a renewed sense of public confidence that their local
services can demonstrate the highest standards in terms of safety, quality care and
experience.
The only way we have been able to make these improvements is through the
commitment and hard work of our staff. The Trust Board and I firmly believe that
those providing services are best placed to identify areas for improvement and
develop the best solutions. In 2012/13 we launched the ‘Making it Better Together’
programme which aimed to empower colleagues to drive forward the changes that
will improve the quality of our services and the experience of our patients and staff.
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There is always more we can do and in 2013/14 we will continue our journey to
consistently match the best performers in the NHS. The way in which we deliver
care is equally important as the care itself. We will therefore focus on areas where
we know there is the greatest opportunity for improvement as set out in our 2013/14
Operating Plan.
We have also been focusing on how quality and safety can be sustainably achieved
beyond 2013/14. In this context we have also been developing our clinical service
strategy which will ensure future services are sustainable with a high quality
responding to national workforce challenges and future service standards. The
future clinical models proposed have been jointly developed by clinicians working
together across primary and hospital services. Commissioner led public consultation
on these models and the future configuration of hospital services will conclude at the
end of May 2013. The driving force behind our clinical service strategy is providing
safer, higher quality care. Integral to the strategy is establishing sound foundations
in our finances, workforce and partnerships with stakeholders and other local
providers of health and social care services. More information on our clinical service
strategy is available at: www.meetingthechallenge.co.uk.
The Trust has also established a Community Service Provider Task Force which
brings together health and social care partners to deliver substantial transformation
in local community services. The strategic aims of the Taskforce are;
•
To deliver a shared vision for Health and Wellbeing, preventative and
integrated services across the spectrum of health and social care services
•
To drive forward opportunities for cooperative working where this has the
potential to improve service quality, increase efficiency or help reduce costs
•
To develop a range of integrated services which meet and exceed the
outcomes and standards expected by commissioners
•
To provide a strong focus on leading edge practice and innovation and the use
of technologies to continuously improve services
•
To establish a development programme to ensure there is a strong local
network of leaders committed to delivering a shared vision and programme of
change and transformation.
The programme is underpinned by a benefits management strategy and process
which is designed to drive clarity, discipline and delivery.
In common with all other NHS providers the Trust will have to respond to a range of
national and local challenges, such as the shift in commissioning to GPs in the form
of clinical commissioning groups, national workforce challenges, continued financial
pressures in ensuring we are doing more for less whilst not compromising standards
and experience. I am confident that now we have started to develop a proven track
record of responding to challenges we will able to demonstrate and reflect on
another year of improvements at the end of 2013/14.
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We have set out our Quality Accounts in accordance with the Department of Health
guidelines. The Board of Directors confirm that to the best of our knowledge this
report complies with the requirements and is satisfied that the information contained
herein is accurate.
Stephen Eames
Interim Chief Executive
April 2013
Our Vision and Values Our vision for the future has been shaped by listening to the
opinions and experiences of our patients and those close to them, along with the
views and priorities of our staff and other key stakeholders.
The values that we hold as an organisation and colleagues are fundamental as they
guide and shape our behaviours; one of the key features of a successful
organisation is how we interact with each other and the local people who rely on us
for their care. We are therefore focusing on culture as the next stage of broadening
our ‘Making it Better Together’ programme. The ‘right’ culture is the cornerstone of
effective organisations and focusing on this will help make our services even better.
Work on our values began some time ago when all staff as well as volunteers, public
representatives and partner organisations were asked to tell us what they felt our
values should be.
Through this process we have agreed the following core values;
These values were formally launched in May 2013 and are currently being rolled out
in a phased approach across the year. They are not descriptions of the work we do,
or the strategies we employ to accomplish our mission. They should not be
competencies that you go on a training course to learn. Our values underlie our
work, and describe what we, as a Trust, stand for and guide us towards making the
best decisions for our patients and ourselves.
An important aspect of the roll out programme for each value is identifying, sharing
and adopting as much best practice as possible starting with ‘Caring’ and how we
ensure quality of care is at the heart of everything we do.
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We recognise the impact that significant changes within the organisation can have
on staff morale and through patient care. It is vital that we therefore listen to and
respond to all information and feedback from our staff. .
We will do this by undertaking more detailed analysis of the local staff survey results
and by using them to identify key issues, which then will be translated into Divisional
and Trust wide action plans aligned to our organisational values.
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1.2 Our Corporate Objectives
In order to deliver our vision and values in a practical, operational way we have set
out our corporate objectives which show how we will use our principles to drive our
business forward. The key Mid Yorkshire Hospitals NHS Trust objective is to be in
the top 25% performing Trusts in 2013/14 and in the top 10% by 2014/15, followed
by a revision to Foundation Trust Trajectory for Foundation Trust application. In this
respect the objectives, improvement areas and development priorities must be able
to directly contribute to improving quality, safety and public confidence in services
reflected in the Trust reputation.
The corporate objectives and priorities for 2013/14 have been developed over a
number of months involving our clinical divisions, corporate departments and Trust
Board. The objectives are designed to ensure the Trust focuses on quality,
sustainability and delivery across all aspects of the organisation. The objectives are
outlined below;
Building continuous
quality
improvement and
governance
Build clinical
networks and
partnerships
Develop Board
leadership and
governance
Complete the Full
Business Case for
the Clinical Service
Strategy
Deliver rephased
cost improvement
plan
Paradigm change in
staff and patient
engagement
Transform
community services
(Task Force)
Continue improving
service
performance
Change external
perceptions and
reputation through
delivery
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In addition to these objectives the Trust has set the following improvement priorities
and development areas;
Ines
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1.3 Making It Better Together
At the start of 2012/13 the Trust developed our ‘Making it Better Together’
programme as a response to the changes and challenges faced by the organisation.
The Board made a conscious decision that we needed to maintain a real focus on
delivering concrete changes because they were so important to delivering a standard
of care that local people deserve. This was really tough and involved a lot of hard
work on improving our services and getting our finances back on track. We are
starting to reap the benefits in terms of our achievements and how we are perceived
by our stakeholders. Our next challenge is to redress the balance of media focus on
our services which takes longer to turn round.
Making it better together - Aims and Objectives
The key aims of our transformation programme are;
•
•
•
•
•
•
•
•
•
To highlight and ensure awareness of the Trust’s challenges, the necessity for
change and how it will be achieved. This should make particular reference to
poor customer service, the financial challenge, service underperformance and
poor relationships with stakeholders.
To highlight the opportunity for staff to contribute to the change and the
methods available to do this.
To improve staff morale and motivate staff to take responsibility and lead
initiatives that will drive efficiency and improvement. These initiatives can
relate to improvements in a number of areas including patient care and
experience, value for money and staff working lives.
To listen to and incorporate staff’s views in shaping plans where appropriate.
To understand from the staff perspective what the barriers are to better
services and how we can change systems and processes to make our services
better for patients.
To communicate evidence that the views of staff are being taken on board and
influencing strategy and plans.
To ensure that everyone can learn from the best practice delivered by many of
our teams and services and at the same time, systematically share and
implement best practice from the wider NHS.
To provide reassurance that services are being designed so that they are fit for
the future.
To develop and embed the approach of making changes that put the needs of
patients first, and where possible involving patients in devising and
implementing changes to improve the organisation’s external reputation.
The programme has four themes bringing together existing projects and
programmes of work:
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Short term measures and
strengthening control:
Clinical service improvement
Vacancy control
theatre efficiency
Leave and attendance management
outpatient productivitybed utilisation
Reduction of overtime/agency/
costs
Integrating acute and community
services
Reduction in variable pay
Service line analysis and viability
Reduction in WLI rates
Reduction in procurement costs
Engaging with our local communities
and partners and improving customer
experience.
Transforming the workforce
Clinical services strategy and FT
application
Increasing medical staff productivity
Pontefract Optimisation proposals
Nurse management review
Outline Business Case for options for
future delivery of clinical services
emergency care services
Clinical nurse specialist review
Estate rationalisation programme
Admin & clerical review
Public consultation on Clinical service
strategy/FT application
Doctor cover out of hours
Reducing management costs
Revised trajectory for Foundation Trust
pipeline
Ongoing programme
Staff engagement and involvement have been and continues to be fundamental to
the success of the programme, we are using our ‘Making it better together’
programme to embed continuous improvement in the Trust. This is not a one-off
campaign but a new approach to engaging and involving staff over the long-term.
1.4 Nursing and Midwifery Strategy
In September 2012 at our annual nursing conference the Trust launched a newly
developed Nursing and Midwifery Strategy.
This event was attended by key nursing and midwifery leaders and the programme
for the day focused on the 5 domains of care that we must get right if the needs of
patients are to be met by the provision of excellent nursing and midwifery care.
The strategy written by nurses incorporates the national strategy – Compassion in
Practice which is described below.
To support our delivery of these domains we have used the Compassion in Practice
(as developed by the UK Chief Nursing Officer in 2012) in order to fully understand
and ‘drill down’ to the core of what nurses do, how and why it should be done.
These are:
1. Care – what we do day to day, we take care of people.
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2. Compassion – not what we do, but how we do it, treating patients with dignity
and respect.
3. Commitment – there needs to be a nursing commitment to improve
outcomes and do the right thing.
4. Communication – we must think about the way we communicate with
colleagues and managers as well as patients, relatives and carers.
5. Courage –being brave enough to do the right thing and speak up when you
are not happy with something your organisation is doing.
6. Competence – the combination of skills, knowledge and attitudes, values and
technical abilities that underpin safe and effective nursing practice.
The aim is that nurses and midwives at MYHT will demonstrate that they are proud
of their professions, work in a way that they achieve respect for the profession and
deliver safe and effective care with excellent patient experience.
Our strategy to deliver these outcomes is as follows:
• Get staffing right – delivering excellent care combined with good
communication and competent staff
• Deliver care that is competent and compassionate
• Measure impact using commitment, communication and courage
• Patient experience, delivering excellent care and communication with
compassion
• Staff experience enhanced by being committed, competent and courageous
The strategy document describes what we will do to achieve our intended outcomes
and provides many examples of how we will deliver the key actions.
(http://nww.midyorks.nhs.uk/Departments/nursing_quality/Documents/Nursing%20an
d%20Midwifery%20Strategy%202012%C2%AD2015%20V6%20LRES.pdf)
Our strategy provides a vision for our staff and clarity on the future contribution and
direction of nursing in the Mid Yorkshire Hospitals NHS Trust. Our vision combines a
compassionate care giving approach, with delivering personal, safe and effective
services to anyone who needs them across the areas we serve.
Nursing and midwifery leadership will provide a vital and key role in taking this
strategy forward, to continually improve service care and delivery. This will
encourage autonomy, responsibility and accountability in nursing and midwifery at all
levels.
1.5
Staff Survey
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The results of the NHS Staff Survey undertaken in 2012 showed us that whilst we
are definitely improving, we still have some way to go to meet our objective to be in
the top 10% of Trusts by 2014/15.
The NHS Staff survey identifies priority areas and immediate next steps. Of the 850
staff surveyed this year 397 completed and returned a survey questionnaire.
Unfortunately this response rate of 47% represented a 7% decrease from the 2011
survey and was below average for acute Trusts.
In 2011, 74% of the key findings from the survey were below average. In 2012 this
significantly improved with 50% being average or better and 50% below average.
However, there are some significant key findings where the Trust remains in the
worst 20% for acute Trusts i.e.
•
•
•
•
Staff recommendation of the Trust as a place to work or receive treatment.
Staff motivation at work.
Staff reporting errors, near misses or incidents and agreeing that incident
reporting procedures are fair and effective.
Staff having well structured appraisals
In addition, the percentage of staff reporting that they have felt unwell in the last 12
months as a result of work related stress has increased by 8% to 40%. Furthermore
72% stated that in the last three months they had gone to work despite not feeling
well enough to perform their duties, an 8% increase from 2011.
As in previous years, the detailed content of the questionnaire has been summarised
and presented in the form of key findings which are arranged under the four staff
pledges from the NHS constitution, plus the additional themes of staff satisfaction
and equality and diversity. An employee engagement score is also included.
Staff Pledge 1: To provide all staff with clear roles and responsibilities and
rewarding jobs for teams and individuals that make a difference to patients, their
families, carers and communities.
Staff Pledge 2: To provide all staff with personal development, access to
appropriate training for their jobs and line management support to succeed.
Staff Pledge 3: To provide support and opportunities for staff to maintain their
health, well-being and safety.
Staff Pledge 4: To engage staff in decisions that affect them and the services they
provide, individually, through representative organisations and through local
partnership working arrangements. All staff will be empowered to put forward ways
to deliver better and safer services for patients and their families.
Results Overview
The number of categories where the Trust has achieved the best scores for acute
Trusts has significantly increased in 2011 as have the number of categories where
the Trust has improved to achieve average results. The number of categories where
the Trust is worse than average or in the worst category has also significantly
improved.
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Overall, the Trust results comparable with 2011 are as follows;
2011
Number of
Key Findings
Category
2012
Number of
Key Findings
Category
2 (5%)
best
5 (18%) 
best
4 (10.5%)
better than
average
3 (11%) 
better than
average
4 (10.5%)
average
6 (21%) 
average
11 (29%)
worse than
average
5 (18%) 
worse than
average
17 (45%)
worst
9 (32%) 
Worst
NB: In 2011 there were 38 key findings. In 2012 there are 28 key findings.
Key findings from the survey:
The outcome of the survey is presented in two ways;
Percentage scores, i.e. percentage of staff giving a particular response to one,
or a series of, survey questions.
•
Scale summary scores, calculated by converting staff responses to particular
questions into scores. For each of these scale summary scores the minimum
score is always 1 and the maximum score is 5.
•
Staff Pledge 1: To provide all staff with clear roles and responsibilities and
rewarding jobs for teams and individuals that make a difference to patients, their
families, carers and communities.
Key Factor
1
2
% of staff feeling
satisfied with the
quality of work and
patient care they are
able to deliver
% of staff agreeing
that their role makes
a difference to
patients
 2012 2011 2010 Average
for
acute
Trusts
2012

73% 70% 77% 78%
Position
(compared
with all acute
Trusts in
2012)
Lowest
(worst) 20%

Below (worse
than) average
89%
88%
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93%
89%
3
Work pressure felt by
staff
--
3.05
--
--
3.08
Average
4
Effective team
working
% working extra
hours

3.70
3.69
3.73
3.72
Average

67%
61%
61%
70%
Below (better
than) average
5
Staff Pledge 2: To provide all staff with personal development, access to
appropriate training for their jobs and line management support to succeed.
Key Factor

201
2
201
1
2010
6
% receiving jobrelevant training,
learning or
development in last 12
months
--
79
%
--
7
% of staff appraised in
last 12 months

84
%
8

% of staff having well
structured appraisals in
last 12 months

Support from
immediate managers
28
%
9
--
Averag
e for
acute
Trusts
2012
81%
Position
(compared
with all acute
Trusts in
2012)
Below (worse
than) average
72
%
83%
84%
Average
29
%
36%
36%
Lowest
(worst) 20%
3.59 3.53 3.55
3.61
Below (worse
than) average
Staff Pledge 3: To provide support and opportunities for staff to maintain their
health, well-being and safety.
Key Factor
10
11
12


201
2
201
1
Occupational Health and Safety

% of staff receiving
76
78
health and safety
%
%
training in last 12
months

% of staff suffering
39
30
work-related stress in
%
%
last 12 months
Infection control and hygiene

% saying hand
60
66
washing materials are
%
%
always available
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201
0
Average
for acute
Trusts
2012
Position
(compared
with all acute
Trusts in 2012)
86
%
74%
Above (better
than) average
26
%
37%
!Above (worse
than) average
71
%
60%
Average
Key Factor
13
14
15
16
17
18
19
20


201
2
Errors and Incidents

% witnessing
27
potentially harmful
%
errors, near misses or
incidents in last month

% of staff reporting
88
errors, near misses or
%
incidents witnessed in
the last month

Fairness and
3.4
effectiveness of
2
procedures for
reporting errors, near
misses or incidents
Violence and Harassment
% of staff experiencing -12
physical violence from
%
patients/relatives in last
12 months
% experiencing
-1%
physical violence from
staff in last 12 months
% of staff experiencing -30
harassment, bullying or
%
abuse from
patients/relatives in last
12 months
% of staff experiencing -22
harassment, bullying or
%
abuse from staff in last
12 months
Health and well-being

% feeling pressure in
33
last 3 months to attend
%
work when feeling
unwell
201
1
201
0
Average
for acute
Trusts
2012
Position
(compared
with all acute
Trusts in 2012)
31
%
30
%
34%
Lowest (best)
20%
97
%
97
%
90%
Lowest (worst)
20%
3.36 3.40 3.50
Lowest (worst)
20%
--
--
15%
Lowest (best)
20%
--
--
3%
Lowest (best)
20%
--
--
30%
Average
--
--
24%
Lowest (best)
20
25
%
27
%
29%
Highest
(worst) 20%
Staff Pledge 4: To engage staff in decisions that affect them and the services they
provide, individually, through representative organisations and through local
partnership working arrangements. All staff will be empowered to put forward ways
to deliver better and safer services for patients and their families.
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Key Factor
21
22
23
24
25
26

201
2
201
1
% of staff reporting good -19% -communication between
senior management and
staff

% able to contribute
66% 51%
towards improvements at
work
Additional Theme: Staff Satisfaction

Staff job satisfaction
3.50 3.36
% of staff that would
recommend the Trust as
a place to work
Staff motivation at work
201
0
Position
--
Averag
e for
acute
Trusts
2012
27%
59%
68%
Below (worse
than) average
3.48
3.58
Lowest
(worst_ 20%
Lowest
(worst_ 20%
Lowest
(worst_ 20%

3.02
3.23
3.34
3.57

3.66
3.70
3.82
3.84
Lowest
(worst_ 20%
55%
Average
Additional Theme: Equality and Diversity
% of staff having equality 
53% 36% 53%
and diversity training in
last 12 months
27
% of staff believing Trust 
provides equal
opportunities for career
progression or promotion
28
% experiencing
discrimination at work in
last 12 months

90%
87%
91%
88%
Above (better
than) average
8%
12%
10%
11%
Lowest (best)
20%
There are a number of areas where the Trust needs to make further progress where
it is in the worse 20% for acute Trusts. Some of these key findings were included in
previous years’ action plans but have not resulted in the level of improvements
expected.
Specific priority areas are as follows:
•
Staff recommendation of the Trust as a place to work or receive treatment
•
Communication between senior management and staff
•
Reporting of errors, near misses or incidents and the fairness and effectiveness
of incident reporting procedures.
•
Staff engagement
•
Staff feeling satisfied with the quality of work and patient care they are able to
deliver
•
Staff having well structured appraisals
•
Staff motivation at work
•
Work related stress
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In January 2013, the Trust undertook its own local survey in order to obtain more
qualitative information on the priority areas. A paper survey was attached to January
payslips but staff also had the option to complete electronically. 1200 responses
were received and the information provided has been used to inform the action plan
which has been developed to address the priority areas. Further work will also be
undertaken including a “you said, we listened” campaign to demonstrate to staff that
their feedback has been listened to and acted upon.
1.6 Inpatient Survey
Patient experience is now recognised as one of the central elements of quality in the
NHS in England. If patients and their families are at the heart of healthcare, as they
should be then their views and understanding their experiences are crucial if we are
to develop and improve our services. Really listening to what patients have to tell
us, allows us to design the type of services they need and will use.
Our annual adult inpatient survey has been externally evaluated by the Picker
Institute as this ensures we have a balanced and fair view of Trust’s performance.
The report was published in February 2013 and the data in the report is used
nationally to feed into the Care Quality Commission (CQC) inpatient survey report.
The CQC inpatient report allows Trusts to benchmark themselves against 155 other
acute trusts.
A sample of 850 patients in each Trust were given the opportunity to provide their
views on their hospital stay in areas such as their experience in A&E, waiting times,
the hospital and wards, doctors, nurses, care, treatment, operations, procedures and
discharge. The survey was carried in July 2012 and of the eligible sample, 397
patients completed the questionnaire.
The CQC report benchmarks the local surveys from all Trusts and shows that in the
majority of areas, we compare well with other Trusts across the country. We are
very pleased that we are also reported as being among the best performers
nationally for not re-arranging a patients’ admission date and in providing support for
patients in eating their meals.
The report does however highlight areas where we did not compare favourably
including overall views and experience, the perception of enough nurses being on
duty and in providing patients with clear information on medicines. The report also
shows a small number of patients sharing a sleeping area with patients of the
opposite sex in critical care areas and how patients rated the hospital food. Our aim
is to address these concerns, reorient service goals and improvement processes
based on this feedback.
The survey results need to be viewed in context of rapid improvements which have
been implemented since July 2012 when the survey was undertaken. Since that
time we have seen really positive results in key areas such as our Nurse Sensitive
Indicators and in our overall performance across the Trust including our four hour
emergency care target, where we are one of the best performers nationally. This is
down to the hard work of staff and is something to be very proud of.
We have also introduced the Friends and Family Test, which gives every inpatient
and patient attending A&E the opportunity to provide feedback on their experience to
Page 18 of 93
us. This provides us with direct patient feedback more quickly, which will really help
us to understand where we are doing well but more importantly what we need to
target to put improvements in place on an ongoing basis. Early feedback has been
really positive about our services, something which is echoed by our excellent
performance over the last financial year.
We know that providing our patients with good quality written or printed information
about their medicines is an area we need to make improvements. This is why we
will be changing the information provided to patients to make sure they receive clear
medicine summaries when needed. We also have a project group which is looking
at the best way to provide patients with good quality and helpful information on
discharge.
Whilst the inpatient survey shows areas that we really need to focus on we also need
to look at the wider picture. We have a lot to be positive about and the fact that we
have maintained our performance in the majority of areas and are considered among
the best Trusts nationally in some areas, reflects the hard work and commitment of
staff and the improvements that we have put in place.
In summary the CQC benchmark report highlights:
We are better than other trusts in questions relating to the following areas;
1.
2.
Was your admission date changed by the hospital
Did you get enough help from staff to eat your meals
We are worse than other trusts in the following areas:
•
•
In your opinion, were there enough nurses on duty to care for you in hospital
Were you given clear written or printed information about your medicines
We are about the same as other trusts in all other areas.
This report was published on 16 April 2013 on the CQC website and an action plan
has been developed to address the areas that need improvement. We know that we
now have a four month window of opportunity for improvement prior to the national
survey being undertaken again in July 2013.
Page 19 of 93
Part Two: Priorities for improvement and statements of assurance from the
Board
In part two of our report we set out our quality priorities for the coming year 2013/14
and we include statements of assurance from the Board regarding the quality of the
NHS services that we provide.
Throughout the year the Trust has engaged with the Quality Clinical Governance
Committee (QCGC), Local Improvement Networks (LINk), Overview and Scrutiny
Committee (OSC), Joint Consultative Negotiating Committee (JCNC) and the Mid
Yorkshire Hospitals commissioner-led Executive Quality Board to discuss priorities
for 2013/14.
2.1 Our quality priorities for 2013/14
Mid-Yorkshire Hospitals NHS Trust has quality of care at its very heart and we are
committed to ensuring the safety of all our services and providing a consistently first
class patient experience. In support of our quality priorities we will also be
developing and then implementing a quality strategy in 13/14
Our quality priorities for 2013/14 are as follows:
1. To reduce methicillin sensitive staphylococcus aureus (MSSA) blood infections
by a third compared with 2012/13
2. To maintain mortality rates below the national average
3. To improve patient reported outcome measures (PROMS) for joint replacements
4. To increase incident reporting rates to that of the top 25% of Trusts
5. To reduce harm from falls by 25% compared with 2012/13
The rational for the chosen priorities is:
•
We have continued to achieve reductions in the numbers of hospital acquired
infection cases. We are pleased with our reduction in the numbers of clostridium
difficile cases and want to achieve a greater reduction in the numbers of MRSA
bacteraemia cases. This is one of our improvement priorities in our operating
plan.
Our improvement action plans have been developed to enable us to make
improvements across the range of Health Care Associated Infections (HCAI) and
this year we will focus more closely on the reduction in MSSA cases. Many of the
actions required to prevent these cases are similar to those required for MRSA
cases therefore we hope to benefit two fold and will demonstrate zero tolerance
approach to all HCAI.
•
The Francis report clearly emphasizes the importance of mortality as an
important indicator of patient safety. We are making progress in reducing hospital
mortality. The processes that we put in place previously we will continue with;
monthly HSMR meetings, revised patient safety panel. Over the last 12 months
our rates are lower than the national average however as organisations nationally
continue to improve so we also need to continue to improve. We will therefore
have an updated action plan to deliver the required changes to ensure further
Page 20 of 93
•
•
•
improvements. We consider this to be a headline driver for quality and know that
this is an important area for public confidence.
We undertake high volume joint replacement procedures and recognise that a
good quality outcome from this surgery is important for our patients. This group of
patients are often elderly and can be vulnerable and we need to ensure that we
improve quality of life. We need to understand more about our PROMS outcomes
and ensure that the care we provide benchmarks well with other organisations.
Incident reporting is a marker of a strong and open patient safety culture.
Historically we have benchmarked low when compared nationally; in the main
this has been due to a technical issue in reality we are amongst the average for
reporting of incidents. Increasing reporting will enable us to better understand the
risks and improve our learning and our ability to have a wide reaching impact on
quality and safety.
As an organisation which aims to reduce harm we are committed to reviewing
and understanding why patients fall within our system. We have been collecting
data for over a year on 100% of our inpatients in a snap shot audit once per
month and we will use this data to help us look at the care we give and help us to
understand where we can make improvements.
We will deliver these by:
Priority 1 To reduce methicillin sensitive staphylococcus aureus (MSSA) blood
infections by a third compared with 2012/13
 Actions to deliver:
 Improving the management of patient’s with a urinary cathetercatheter care record
 Improving compliance with antibiotic management
 Clinical skills training for healthcare workers involved in invasive
device management
 100% compliance with ANTT for frontline staff
 Improve compliance with clinical equipment cleaning – monitored
through the High Impact Intervention audits
 Environmental cleaning standards
Priority 2 To maintain mortality rates below the national average
 Actions to deliver:
 Mortality steering group
 Specialty mortality reviews
 Mortality reduction plan
Priority 3 To improve PROMS for joint replacements
 Actions to deliver:
 Ensure coding correct
 Review patient experience for each type of replacement
 To examine and implement best practice from elsewhere
Page 21 of 93
Priority 4 To increase incident reporting rates to that of the top 25% of Trusts
 Actions to deliver:
 To performance manage timely management of incident
 To implement mandatory feedback to the reporter
 To have themed initiatives to encourage incident reporting
 To use National Reporting and Learning System (NRLS)reporting
rates as benchmark
 To notify the NRLS of incidents when reported rather than when
closed
Priority 5 To reduce harm from falls by 25% compared with 2012/13
Actions to deliver:
 Use Falls Assessment Tool to identify patients at risk of falls
 Continued use of aids to prevent falls
 Monitor prevalence through the use of the Patient Safety
Thermometer
 Identify Falls Champions
 Share learning
 Identify and implement best practice from other Trusts
Supporting delivery of our Quality Priorities
In support of the delivery of our quality priorities we have developed key corporate
objectives within our Annual Plan to underpin year their delivery and support our
aspiration to Foundation Trust status. These objectives are set out in Part One of this
document.
Each will have a target that is measurable (performance indicator) which will be
incorporated in the integrated performance report which is published monthly in
public board reports the board will therefore oversee progress against the target and
the trajectory for each priority.
Individual action plans will be reviewed by the Quality and Clinical governance
committee ensuring that any variance are investigated and addressed as well as
cascading areas of improvement and excellent performance.
The Quality and Clinical Governance committee will receive reports on a quarterly
basis and provide assurance to the Trust Board that progress is being made.
Progress with these plans will be transparent involving our key stakeholders such as
our Stakeholder Group, Health watch, and our commissioners.
2.2 Statements from the Board
In addition to setting out our aspirations for the coming year and our review of our
performance against our quality priorities in 2012/13 which we will set out in part 3 of
this report, we are required to include commentary regarding our statutory quality
targets and other obligations and priorities. These areas are covered in the following
sections.
Page 22 of 93
During 2012/13 the Mid Yorkshire Hospitals NHS Trust provided and/or subcontracted 95 relevant health services.
The Mid Yorkshire Hospitals NHS Trust has reviewed all the data available to them
on the quality of care in 84 of these relevant health services.
The income generated by the relevant health services reviewed in 2012/13
represents 98 per cent of the total income generated from the provision of relevant
health services by the Mid Yorkshire Hospitals NHS Trust for 2012/13.
2.2.1 Clinical Audit
Participation in Clinical Audits 2012-13
Clinical audit is at the heart of clinical governance and quality assurance: it provides
an important mechanism for reviewing the quality of healthcare. During 2012/13, 47
national clinical audits and three national confidential enquiries covered NHS
services that The Mid Yorkshire Hospitals NHS Trust provides. During that period
The Mid Yorkshire Hospitals NHS Trust participated in 72.34% national clinical
audits and 100% confidential enquires which it was eligible to participate in. The Mid
Yorkshire Hospitals NHS Trust was eligible to participate in during 2012/13 are as
follows:
Name of Audit
Peri and Neo-natal
Neonatal intensive and special care (NNAP)
Children
Paediatric pneumonia (British Thoracic Society)
Paediatric asthma (British Thoracic Society)
Paediatric Intensive Care (PICANet)
Epilepsy 12 (Childhood epilepsy) (RCPH National Childhood
Epilepsy Audit)
Fever in children (College of Emergency Medicine)
Paediatric cardiac surgery (NICOR Congenital Heart Disease Audit)
Diabetes (RCPH National Paediatric Diabetes Audit)
Acute Care
Emergency use of oxygen (British Thoracic Society)
Adult community acquired pneumonia (British Thoracic Society)
Non invasive ventilation -adults (British Thoracic Society)
Cardiac arrest (National Cardiac Arrest Audit)
Adult critical care (ICNARC CMPD)
Long Term Conditions
Diabetes (National Adult Diabetes Audit)
Inflammatory Bowel Disease
Page 23 of 93
NCAPOP
audit and
Quality
Account
audit
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No
No
No
No
No
Yes
Yes
Pain Database (National Pain Audit)
Parkinson's disease (National Parkinson's Audit)
Adult asthma (British Thoracic Society)
Bronchiectasis (British Thoracic Society)
Yes
No
No
No
NCAPOP audit
and Quality
Account audit
Name of Audit
Elective Procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMs Programme)
Intra-thoracic transplantation (NHSBT UK Transplant Registry)
Liver transplantation (NHSBT UK Transplant Registry)
Coronary angioplasty (NICOR Adult cardiac interventions audit)
Peripheral vascular surgery (VSGBI Vascular Surgery Database)
Carotid interventions (Carotid Intervention Audit)
CABG and valvular surgery (Adult cardiac surgery audit)
Yes
Yes
No
Yes
Yes
No
Yes
No
Cardiovascular Disease
Acute Myocardial Infarction & other ACS (MINAP)
Yes
Heart failure (Heart Failure Audit)
Yes
Stroke National Audit Programme (combines Sentinel and
SINAP) (SSNAP)
Yes
Cardiac arrhythmia (Cardiac Rhythm Management Audit)
Yes
Pulmonary Hypertension Audit
No
Renal Disease
Renal replacement therapy (Renal Registry)
Renal transplantation (NHSBT UK Transplant Registry)
Renal Colic
No
No
No
Cancer
Lung cancer (National Lung Cancer Audit)
Bowel cancer (National Bowel Cancer Audit Programme)
Head & Neck cancer (DAHNO)
Oesophago-gastric cancer (National O-G Cancer Audit)
Yes
Yes
Yes
Yes
Trauma
Hip fracture (National Hip Fracture Database)
Severe trauma (Trauma Audit & Research Network)
Fractured Neck of Femur
Yes
No
No
Psychological Conditions
National Audit of Dementia
Yes
Page 24 of 93
Page 25 of 93
NCAPOP audit
and Quality
Account audit
Name of Audit
Blood and Transplant
Audit of Blood Sampling and labelling (National Comparative
Audit of Blood Transfusion)
No
Potential donor audit (NHS Blood & Transplant)
No
Health promotion
Risk Factors - National Health Promotion in Hospitals Audit
No
End of life
Care of dying in hospital (NCDAH)
Yes
National Confidential Enquiries
Maternal & Neonatal Deaths & Serious Morbidity
Medical & Surgical Deaths & Serious Morbidity (NCEPOD)
Childhood Deaths & Serious Morbidity (RCPCH)
Asthma Deaths (NRAD)
Yes
Yes
Yes
Yes
The national clinical audits and national confidential enquires that The Mid Yorkshire
Hospitals NHS Trust participated in, and for which data collection was completed
during 2012/13, are listed below alongside the number of cases submitted to each
audit or enquiry as a percentage of the number of registered cases required by the
term of that audit or enquiry are listed below.
Name of audit
Participation % of Cases
Peri-and Neo-natal
Neonatal intensive and special care
(NNAP)
Yes
Data Period Jan to
Dec 2012
Admissions 454
Audited 454 (100%)
Yes
56/’56 (100%)
Yes
60/60 (100%)
No
Not applicable to
MYHT as all patients
are transferred to
Leeds
Children
Paediatric pneumonia (British Thoracic
Society)
Paediatric asthma (British Thoracic
Society)
Paediatric Intensive Care (PICANet)
Page 26 of 93
Name of audit
Participation % of Cases
Epilepsy 12 (Childhood epilepsy) (RCPH
National Childhood Epilepsy Audit)
Yes
37/37 (100%)
Fever in children (College of Emergency
Medicine)
No
Paediatric cardiac surgery (NICOR
Congenital Heart Disease Audit)
Diabetes (RCPH National Paediatric
Diabetes Audit)
Acute Care
Emergency use of oxygen (British
Thoracic Society)
Adult community acquired pneumonia
(British Thoracic Society)
Non invasive ventilation -adults (British
Thoracic Society)
No
Due to overwhelming
clinical pressure at
time of audit
Not applicable
transferred to Leeds
Sample 187
Audited 187 (100%)
Cardiac arrest (National Cardiac Arrest
Audit)
Yes
Yes
Yes
548/548 (100%)
Yes
37/37 (100%)
No
Actions still ongoing
which were identified
from the 2011-12
National Audit.
Figures are for 1.4.12
– 31.12.12 as the data
for Quarter 4 is being
inputted now.
PGH 257 DDH 153
Actual number of
cardiac arrests
PGH 100 DDH 51
Adult critical care (ICNARC CMPD)
Yes
Emergency Laparotomy Audit
No
Long Term Conditions
Diabetes (National Adult Diabetes Audit)
Yes
Inflammatory Bowel Disease
Pain Database (National Pain Audit)
Yes
Yes
Page 27 of 93
Number of actual
individual patients
PGH 96 DDH 48
100%
(706 PH, 304 DDH)
Due to ongoing
tendering process no
data has been required
for collection for 12-13.
124/124 (100% of
sample)
12/12 (100%)
Patient Survey Sample
225
Response 11 (49%)
Patient choice as to
whether they
Name of audit
Participation % of Cases
participate in audit
Parkinson's disease (National Parkinson's
Audit)
Adult asthma (British Thoracic Society)
Yes
27/27 (100%)
Yes
53/53 (100%)
Bronchiectasis (British Thoracic Society)
No
Due to large amount of
BTS audits it was
decided to not
participate at the audit
in the previous
financial year 2012/13.
The audit was part of
the current Annual
Audit Programme
2013/14; however data
collection will not take
place this year as just
notified by Healthcare
Quality Improvement
Partnership
Asthma Deaths (NRAD)
Yes
3/3 (100%)
Elective Procedures
Hip, knee and ankle replacements
(National Joint Registry)
Yes
Uploaded:
PGH (86%)
DDH (81 %)
Quarter 4 – Changes
to upload procedure
ongoing. Data will
continue to be
populated until 100%
compliance is
achieved
Elective surgery (National PROMs
Programme)
• Hips
• Knees
• Varicose Vein Surgery
• Groin Hernia Surgery
Intra-thoracic transplantation (NHSBT UK
Transplant Registry)
Yes
Hips (100%)
Knees (100%)
Varicose Veins (100%)
Groin Hernia (100%)
No
Page 28 of 93
Not applicable to
MYHT as this is
undertaken at Leeds
Name of audit
Participation % of Cases
Liver transplantation (NHSBT UK
Transplant Registry)
No
Coronary angioplasty (NICOR Adult
cardiac interventions audit)
Yes
Peripheral vascular surgery (VSGBI
Vascular Surgery Database)
Yes
Not applicable to
MYHT as this is
undertaken at Leeds
291 (100%) submitted
for 2012
188/188 (100%)
AAA elective and
emergency 50
AAA elective 35
emergency 15
Lower limb bypass
elective and
emergency 93
Lower limb bypass
elective 59 emergency
44
Amputation elective
and emergency 45
Amputation elective 9
emergency 36
Carotid interventions (Carotid Intervention
Audit)
CABG and valvular surgery (Adult cardiac
surgery audit)
Yes
42 (100%)
No
Not applicable to
MYHT as this is
undertaken at Leeds
Cardiovascular Disease
Acute Myocardial Infarction & other ACS
(MINAP)
Yes
Heart failure (Heart Failure Audit)
Yes
Stroke National Audit Programme
(combines Sentinel and SINAP) (SSNAP)
Yes
1600 records
submitted each year
(100%)
1000 (100%)
submissions
Organisational audit
completed. Data
collection ongoing
Page 29 of 93
Name of audit
Participation % of Cases
Cardiac arrhythmia (Cardiac Rhythm
Management Audit)
Yes
Brady pacemaker
implants: 281
Brady pacemaker box
change: 53
CRTP implants: 47
ICD/CRTD implants:
59
ICD/CRTD box
change: 12
Loop recorders: 16
Pulmonary Hypertension Audit
No
Not one of the 8
designated National
centre which
undertake this
procedure. Therefore
not applicable for
MYHT
Renal Disease
Renal replacement therapy (Renal
Registry)
No
Not applicable to
MYHT as this is
undertaken at Leeds
Not applicable to
MYHT as this is
undertaken at Leeds
Renal transplantation (NHSBT UK
Transplant Registry)
No
Renal Colic
No
Due to overwhelming
clinical pressure at
time of audit not
participated
Cancer
Lung cancer (National Lung Cancer Audit)
Yes
466/466 (100%)
Bowel cancer (National Bowel Cancer
Audit Programme)
Yes
283/283 (100%)
Head & Neck cancer (DAHNO)
Yes
94/94 (100%)
Oesophago-gastric cancer (National O-G
Cancer Audit)
Yes
41/41 (100%)
37 OG
4 High level Dysplasia
Yes
505/505 (100%)
Trauma
Hip fracture (National Hip Fracture
Database)
Page 30 of 93
Name of audit
Participation % of Cases
Severe trauma (Trauma Audit & Research
Network)
Yes
Data analyzed on a 1st
January to 31st
December basis.
TARN 2012:
PGH submitted 252
TARN accepted as
eligible 219
DDH submitted 84
TARN accepted as
eligible 51
Fractured Neck of Femur
No
Psychological Conditions
National Audit of Dementia
Yes
Due to overwhelming
clinical pressure at
time of audit
45/80 (56%) Low
numbers due to
exclusion criteria
adopted for this audit
(patients with length of
stay > 5 days): most of
the patients with
dementia are moved to
intermediate care as
soon as possible
Organisational
Questionnaire
completed for DDH
and PGH prior to the
notes section of the
audit.
Blood and Transplant
National Comparative Audit of Blood
Transfusion – Audit of blood sampling and
labelling
Yes
PGH Sample 221
Audited 221
(100%)
DDH Sample 184
Audited 184
(100%)
Potential donor audit (NHS Blood &
Transplant)
Yes
Page 31 of 93
PGH Critical Care: 150
deaths, 4 DCD, 3
DBD, 2 DCD Stand
Down's
Name of audit
Participation % of Cases
PGH Emergency
Care: 70 Deaths (only
audit patients 75 years
and under in ED) 0
DCD, 0 DBD
DDH Critical Care: 67
deaths, 2 DCD, 1
DBD, 1 DCD Stand
Down
DDH Emergency
Care: 49 deaths (only
audit patients 75 years
and under in ED) 0
DCD, 0 DBD
Health Promotion
Risk Factors - National Health Promotion in
Hospitals Audit
End of life
Care of dying in hospital (NCDAH)
National Confidential Enquiries
Maternal & Neonatal Deaths & Serious
Morbidity
Medical & Surgical Deaths & Serious
Morbidity (NCEPOD)
1.
2.
3.
4.
N/A
This audit was
withdrawn from
inclusion at national
level for this year but
participated in previous
year
Yes
44/44 (100%)
Yes
Yes
Subarachnoid Haemorrhage
Alcohol Related Liver Disease
Bariatric Surgery
Cardiac Arrest Procedures
MBRRACE has
recently being
awarded the tender for
this audit. No data
entered for 2012 due
to this.
Database only live for
the past 2 week, so
backdating from
January 2013 at
present.
1. Cases included 3
Cases excluded 8
Questionnaires
returned 3
Case notes
returned 3
Site Participating 5
Organisational
questionnaires 0
2. Cases Included 8
Page 32 of 93
Name of audit
Participation % of Cases
Clinical
Questionnaires
returned 5
Case notes
returned 8
Site participating 2
Organisational
Questionnaires 2
3. Cases Included 9
Clinical
Questionnaires
returned 5
Case notes
returned 9
Sites participating 1
Organisational
Questionnaires 1
Report published
October 2012
4. Cases Included 0
Prospective forms
returned 18
Questionnaires
returned 0
Case notes 0
Sites participating 5
Organisational
Questionnaires 5
Childhood Deaths & Serious Morbidity
(RCPCH)
Epilepsy
Yes
Awaiting information
from the RCPCH as to
the figure
The MYHT has participated in 21 other National audits and one confidential enquiry
which are not included in the Quality Account list for 2012-13 and reports have been
released during this timeframe. These are included in the table below.
Other National Audits Participated
Provider
in during 2012-13
% of Cases
National Audit of Intermediate Care
20/20 (100%)
British Geriatrics
Society,
Association of
Directors of
Adults Social
Page 33 of 93
Services,
AGILE, College
of Occupational
therapists, Royal
College of
Physicians,
Royal College of
Nursing, the
NHS
Benchmarking
Network.
British Thoracic
Society
European COPD Audit
Management of young people in
sexual health settings in the United
Kingdom
The British
Association of
Sexual Health
and HIV
(BASHH)
Centre for
Maternal and
Child Enquiries
National
Confidential
Enquiry
Centre for Maternal and Child
Enquiries National Confidential
Enquiry into Head Injuries in
Children (4 year plan)
National review of patients who
underwent
cardiopulmonary resuscitation as a
result
of an in-hospital cardio respiratory
arrest
National
Confidential
Enquiry into
Patient
Outcome and
Death
(NCEPOD)
Other National Audits Participated
in during 2012-13
Reducing the use of Antipsychotic
medication audit – response to
Government letter from the NHS
Yorkshire and the Humber.
Provider
NHS Information
Centre for
Department of
Health
179/179 (100%)
Data 2010 - 2012
Completed December
2012
Completed August 2012.
63/63 (100%)
National Report March
2013
This study started in 2009
until 2012. All children (up
to 15 yrs old) who as a
result of head injury are
transferred and /or
admitted to hospital are
included.
Report due Winter 2013
Report published June
2012
5/5 organisational
questionnaires (100%)
Resus forms received 7
number of cases identified
18
% of Cases
1st round November 2011snapshot audit ward 2
PGH
2nd round - 2012
PGH 20/20 (100%)
DDH 25/25 (100%)
Page 34 of 93
National Children’s Nutrition Survey
National Audit of management of
children with Decreased Conscious
Level (DECON)
National Epilepsy 12 Audit – Royal
College of Paediatrics and Child
Health (RCPCH)
British Thoracic Society National
Asthma Audit November 2010
British Thoracic Society National
Asthma Audit 2011
Royal College of
Paediatrics and
Child Health
Royal College of
Paediatrics and
Child Health
British Thoracic
Society
British Thoracic
Society
BTS National Pneumonia in
Paediatrics Audit 2011
British Thoracic
Society
National Audit Back pain
management: occupational health
Health & Work
Development
Unit in
partnership with
Royal College of
Physicians
Health & Work
Development
Unit in
partnership with
Royal College of
Physicians
NHS Diabetic
Eye Screening
Programme
(Public Health
England)
National audit of record keeping –
occupational health
Screening and Management of
Patients with Diabetic Retinopathy
Other National Audits Participated in
during 2012-13
PASCOM (podiatric Audit in Clinical and
Outcome measurement)
National Thyroid Data Base
National Cancer Patient Survey 2012-13
Provider
March 2010 to May 2012
Sample size 25
Audited 25 (100%)
Completed June 2012
Sample size 14
Audited 14 (100%)
Completed October 2012
Sample size 37
Audited 37 (100%)
Sample size 47
Audited 47 (100%)
Completed July 2012
Sample size 34
Audited 34 (100%)
Completed October 2012
Sample size 56
Audited 56 (100%)
Data collected between 1st
January 2011-December
2012
Report April 2012
Report released April
2012
Audit commenced August
2011
27,629 / 27,629 (100%)
2011-12 reporting
deadline 31/10/12 to allow
collection of follow up
information – date of
actualsubmission14/12/12.
% of Cases
Society of
100%
Chiropodists
and Podiatrists
British
100%
Association of
Endocrine and
Thyroid
Surgeons
Quality Health Sample included 100%
(Response Rate MYH
59% to date)
Page 35 of 93
National Chemotherapy Patient Survey
2012-13
Quality Health
NBCA Surgeon Level Reporting
The
Information
Centre
BAUS
British
Association
Urological
Surgeons
•
•
•
•
•
•
•
•
PCNL
Penile Curvature Surgery
Urethroplasty
Periureteric Junction Obstruction
Endoscopic treatment UTTC
Nephrectomy
Cystectomy
Prostatectomy
Sample included 100%
(Response Rate MYH
81% to date)
100%
Aim is to upload 100%
for each and there is a
Consultant Lead for
each project.
All cancer patients
(100%) are completed.
However we do not
have % compliance
figures for each
individual none cancer
diagnostic group
A further 274 local/other audits where completed by The Mid Yorkshire Hospitals
NHS Trust. All National and local audits are disseminated at the MYHT Rolling
Programme Clinical Governance Half days which are held monthly, Divisional
Governance Committees and individual service group meetings where actions plans
are developed and monitored. The results of National audits are discussed at the
Quality and Clinical Governance Committee and prior to this, the Governance
Interface Group (GIG) and individual Divisional Governance committees.
This does not include any independent audits which have been registered with the
Divisions.
The Division of Medicine and The Integrated Care Division have produced a
supporting document which covers in more details all the other/local audits
completed by their divisions within the timeframe stated in this report. The actions
from these audits are included. This document can be available if required by
anyone following the publication of the Quality Account Report, as this is electronic.
The reports of national clinical audits were reviewed by the provider in April 2012 –
March 2013 and the Mid Yorkshire Hospitals NHS Trust. The following 11 National
audits have been reviewed at the Quality and Clinical Governance Committee since
October 2012 and the Mid Yorkshire Hospital NHS Trust:
•
•
•
•
•
•
•
•
BTS European COPD Audit 2010/11
Stroke Sentinel National Audit (SSNAP) Acute Organisational Audit 2012 has
ensured that the stroke thrombolysis service will be augmented in January
2013 and this should increase thrombolysis rates following this.
Pharmacist Direct Patient Care Activities and Contributions/Interventions
(July 2012)
Dementia/Delirium audit has produced pathways and protocols. Following a
pilot of these pathway they are now operational within the Trust
PROMS Report
National Pain Audit
MINAP
National Lung Cancer Audit 2012
Page 36 of 93
•
Time to Intervene - NCEPOD study
The reports of local clinical audits were reviewed by the provider in April 2012 –
March 2013 and The Mid Yorkshire Hospitals NHS Trust (only few examples given)
and that they intend to take the following actions to improve the quality of healthcare
provided;
•
The Dementia audit has led to further work for patients with MYHT who
develop delirium. Pathways and protocols have been introduced which have
ensured that all up to date guidance and information has been considered
e.g. NICE guidance. Following a pilot of the pathway and protocol, these
have now been implemented within the clinical area. These are available for
all staff to access via the MYHT intranet site.
‘A delirium prevention and management’ policy has been produced and is
available on the intranet site for all staff to refer for this group of patients. An
audit will be undertaken 6 months following implementation of this work.
•
The Re-audit of Red Tray/Jugs & Protected mealtimes has raised the
awareness to all staff of the importance of appropriate use of red tray
systems and protected mealtimes with appropriate clinical evidence and
documentation to support the decision.
•
The Patient Satisfaction Survey undertaken by the Cardio-respiratory
Department has led to modesty gowns being offered to all patients on all
sites.
•
The Gastroenterology services undertake routine annual audits which are
required so that they can maintain their JAG accreditation. The Endoscopy
User Survey 8th Run produced posters which are displayed in the waiting
areas. A4 and A5 patient leaflets to display in the waiting areas. To
encourage more responses to the survey, an electronic version is in the
development stages of being introduced.
•
The Pimecrolimus and Tacrolimus for Atopic Eczema audit, undertaken by
the dermatology services, has led to the production of patient information
leaflets on calcineurin inhibitors (topical immunomodulators).
•
The Audit of the Flexi-Sigmoidoscopy Pathway: which aimed to review the
appropriateness of referrals and use of the patient pathway in accordance
with the NICE guidance for patients with suspected cancer. Resulting actions
developed new processes which avoided unnecessary pre scoping enemas
and made more effective use of sigmoidoscopy slots, resources and review
processes to triage patients, increasing flow through the fast track system for
effective cancer monitoring purposes.
•
Re-audit of Haemolysed Bloods showed a significant improvement in the
number of blood taken on the surgical ward which had haemolysed. The
actions taken from the previous audit included increased shadowing and
training of the junior doctors by the phlebotomy team, and guidance on blood
taking best practice was devised and is now displayed on the surgical wards.
This resulted in significant improvement to the patient experience as repeat
sampling was greatly reduced (more than halved) and the cost efficiency
saving were marked.
Page 37 of 93
•
Anaesthetics Department Audit of Consent in Children: Healthcare
professionals are expected to obtain valid consent when it comes to
treatment for procedures in all patients. This audit identified the complexity in
parental responsibility and a gap in knowledge and understanding regarding
who has legal parental responsibility. The actions identified were to review
and update, with paediatric and safeguarding children input, local consent
documents to include an easy reference of who can consent for a child in
various circumstances. This therefore ensures that the Trust is operating in
line with Children Act 1989 guidance and is ensuring that the most relevant
person is making decisions on behalf of the child.
•
Preoperative Fasting Times in Adults Scheduled for Orthopaedic Surgery:
Patients undergoing surgery should be prepared appropriately before the
procedure to ensure they receive the best possible care and minimise
surgical or anaesthetic risks. Whilst it was identified that patients would
rarely arrive in theatre under fasted the opposite is a common occurrence.
Over fasting patients is known to increase the incidence of complications and
extended recovery period. The actions arising sought to ensure that the preoperative oral intake is not counterproductive to surgery or recovery.
Documentation was amended, including the Trust peri-operative surgical
pathway, orthopaedic operation leaflets and clerking proforma to promote the
safe but not counterproductive pre operative fasting of all surgical patients.
•
The use of Isotoner gloves for patients with rheumatological conditions as
opposed to the use of thermoplastic resting splints was explored by the
Occupational Therapy team.
The aim of the audit was to assess patient experience/compliance and also the
efficacy of using isotoner gloves the gloves to treat hand problems related to
rheumatological conditions.
The objectives:
1. To assess patient satisfaction and compliance in wearing the gloves
2. To assess the gloves ability to control pain, swelling and stiffness in hand
joints.
3. To assess if there were any improvements in hand function after treatment.
4. To ascertain if there were particular conditions which responded better to
treatment (eg OA, RA fibromyalgia, etc)
5. To ascertain if patients preferred the glove compared to the resting splint.
Page 38 of 93
Summary of findings
• The glove did not appear to affect any particular condition more than any
other.
•
The isotoner gloves audit gave clear results that showed subjective
improvements in symptoms of swelling, pain and joint stiffness with patients
that had a rheumatological condition.
•
There was an improvement in pain relief from the patients, as well as an
improvement in function.
•
The patients reported preferring a glove to a splint.
The gloves are easy to fit and quick to provide in comparison to resting splints
(thus saving time and money). They are also cheaper than thermoplastic splint
material and less bulky to wear in bed, helping with compliance issues.
To continue with current practice of isotoner glove provision and inform other
relevant staff in the service of audit results
It is clear that providing the gloves give good treatment outcomes for
rheumatological conditions. It will save therapist time in fabricating resting splints
(the alternative) and the results also show good patient compliance.
Resource implications
Purchase of gloves (however, ordering less thermoplastic material would be the
benefit result)
The Adult Community Nursing Service recognise that issues around medication
information on discharge from hospital is a key concern for many of our patients
(as identified in the PICKER surveys), carrying out an audit which incorporated
that and a number of other areas for potential improvement.
The baseline survey showed a high percentage of patients were satisfied but the
two areas which the Adult Community Nursing Service which the Community
Matrons are part of did not do as well were:
i.
Did staff clearly explain why you need to take your medication and side
effects in a way that you could understand?
ii.
How easy was it to contact the service when you needed them?
•
i.
ii.
The actions for the Adult Community Nursing Service following the baseline
survey for these areas are:
All staff to check when they make a visit what medication the patient is
taking and check that the patient understands how to take their
medication and the side effects. This has become a core role for the
team.
The team will be advised to ensure all patients have the contact details
after each visit for the Single Point of Contact team which take all the
incoming calls for the Adult Community Nursing service 24/7, the calls to
this service are monitored and dealt with in a reasonable time, there may
on occasions be a high call volumes but a call waiting facility is available
Page 39 of 93
2.2.2 Research and Development
The Mid Yorkshire Hospitals NHS Trust is a member of the West Yorkshire
Comprehensive Local Research Network (WYCLRN), and the Trust hosts one of the
four network clusters, providing research and development advice and support to the
Yorkshire Ambulance Service, and NHS Wakefield District.
This partnership working helps the trust to support the NHS Mandate published in
November 2012 which reaffirms the NHS commitment to research. We are focused
on supporting the NHS Commissioning Board’s objective is to ensure that the new
commissioning system promotes and supports participation by NHS organisations
and NHS patients in research funded by both commercial and non‐commercial
organisations, most importantly to improve patient outcomes, but also to contribute
to economic growth. The NHS Operating Framework demonstrates the value of
clinical research as a driver for improving the quality of care, by setting targets to
increase the number of patients recruited into approved studies.
In year, the Trust has continued to work with the WYCLRN to implement the National
Institute for Health Research (NIHR) guidance for research management and
governance in support of national initiatives to improve the quality, speed and coordination of clinical research by removing the barriers within the NHS, unifying
systems, improving collaboration with industry and streamlining administrative
processes.
We have worked to ensure efficient and effective systems and research delivery
models are in place to facilitate the speedy set up and start of NIHR CRN Portfolio
studies. The target is to obtain local NHS permission for studies within 30 calendar
days and our median for this trust is 19 days
The Trust has increased the number of patients recruited into NIHR Portfolio studies,
working towards the NHS Operating Framework goal to double the number of
patients recruited to studies over 5 years.
Between 1st April 2012 and 31st March 2013 301 research studies were active within
the Trust (including studies where patients are being followed up after recruitment
and treatment phases are complete). Of those, 56 studies were new and opened
during 12-13.
The Trust links with the Stroke Research Network, Cancer Research Network,
Diabetes Research Network, Medicines for Children Research Network in addition to
our close working arrangements with West Yorkshire Comprehensive Local
Research Network. These networks provide an infrastructure which the Trust actively
participates in to provide our patients with access to well designed studies and
clinical trials.
The number of patients receiving NHS services provided or subcontracted by Mid
Yorkshire Hospitals in 2012/13 that were recruited during that period to participate in
research approved by a research ethics committee was 1592. 98% (1569) of this
activity is related to research adopted onto the National Institute for Health Research
portfolio of high quality studies.
Page 40 of 93
Mid Yorkshire Hospitals is committed to research as a scientific vehicle for improving
the quality of patient care and experience.
2.2.3 Use of the Commissioning for Quality and Innovation (CQUIN) payment
framework
The Commissioning for quality and innovation (CQUIN) framework, now in its fourth
year, is used by commissioners to agree a set of core quality assurance goals as
part of the service contract. The CQUIN payments seek to place quality improvement
at the centre of the contract for services and they reward excellence by linking a
proportion of income to the achievement of the goals.
A proportion of the Mid Yorkshire NHS Hospitals Trust’s contracted income for
2012/13 was conditional on achieving quality improvement and innovation goals
agreed between the provider and its commissioners (local Primary Care Trusts) and
any person or body they entered into a contract, agreement or arrangement with for
the provision of relevant health services, through the Commissioning for Quality and
Innovation payment framework. Further details of the agreed goals for 2012/13 and
for the following 12 month period are available online at: http://www.monitornhsft.gov.uk/sites/all/modules/fckeditor/plugins/ktbrowser/_openTKFile.php?id=3275
It is vital that the Trust delivers the required quality standards to improve the quality
of care and patient experience, and to ensure this income opportunity is achieved.
CQUIN measures are monitored quarterly.
Data for Quarter 4 is still unvalidated and the final position being negotiated with
Commissioners. The current position is identified in the Table below which
describes the £7m CQUIN funding secured in 2012/13.
Page 41 of 93
CQUIN schemes were developed in 2012/13 such that each of the measures were
made up of a number of separate indicators. For funding to be secured all of the
indicators within a measure had to be improved to the target required.
The Trust could demonstrate improvement in the majority of indicators in 2012/13
but in a small number of cases not to the level decided in the CQUIN. This resulted
in no funding being secured for that particular measure for the quarter. An example
of this would be the Asthma in A&E CQUIN which was made up of 7 indicators. The
Trust could demonstrate improvement in all of the separate indicators however 2 of
them did not meet the required target of improvement. This resulted in failure to
secure the full amount of funding related to this indicator in Quarters 1 and 3.
In 2013/14 measures of this nature have been negotiated to reward the Trust per
indicator and therefore in the example of Asthma would have resulted in 71% of the
income being secured.
2.2.4 Registration and Compliance
The Mid Yorkshire Hospitals NHS Trust is required to register with the Care Quality
Commission (CQC) and is currently registered with CQC to provide a range of
services from the various locations.
The Care Quality Commission (CQC) is an independent national body responsible
for regulating the quality of care provided by NHS trusts, social services and
independent care providers. As a provider of Acute Healthcare Services we are
required to register with the CQC under section 10 of the Health and Social Care Act
2008.
The CQC continually monitors whether The Mid Yorkshire Hospitals NHS Trust, and
other care providers, are meeting their essential standards of quality and patient
safety. Their particular focus is on patient outcomes in terms of the delivery of a
quality experience of care.
The CQC pays particular attention to what people say about the service. The
intelligence which is used by the CQC to make an assessment upon the Trust’s
performance against the statutory standards is obtained from external sources,
including the National Patient Safety Agency, the Parliamentary Health Service
Ombudsman, service users through a dedicated web site, mortality alerts, national
inpatient and staff surveys and through LINks, local charities and voluntary
organisations. The Trust also undertakes a rigorous annual cycle of self assessment,
evidence production and assurance against the quality standards.
The CQC regulates our performance as an organization across 16 essential
outcomes and uses information from a range of sources such as the National Patient
surveys, National Staff Surveys, Information Governance Tool Kit, NHS Litigation
Authority and Hospital Episode Statistics to review whether or not they feel that we
are increasing or reducing the risk of sustaining compliance with each standard. The
Trust receives this information on a regular basis and uses this to determine where
improvements may be required to be made.
For each of the 16 essential outcomes there is a lead that will review the compliance
with the relevant standard and develop actions if required. An internal CQC self
Page 42 of 93
assessment tool has been developed and this is used to undertake CQC style
inspections on inpatient wards. The CQC internal inspections are led by the
associate directors of nursing and the findings reported to the divisional boards.
During 2012/13 CQC inspectors visited the Trust to undertake compliance checks.
An unannounced visit to a service area at Pinderfields hospital led to the CQC
placing a condition on that service. The Trust was required to take immediate actions
to ensure that those services were safe for patients. (an application has been
submitted and the decision on this is awaited.)
The CQC has taken enforcement action against The Mid Yorkshire Hospitals NHS
Trust during 2012/13 and the Trust has participated in special reviews or
investigations by the CQC relating to the following areas during 2012/13:
 An action relating to enforcement (Warning notice) was taken at Dewsbury
and District Hospital under Regulation 22 - Outcome 13 Staffing on
09/04/2012
 An action relating to enforcement (Urgent imposing condition) was taken at
Pinderfields General Hospital under Regulation 15 – Outcome 10 Safety and
suitability of premises on 11/10/2012
 An action relating to enforcement (Warning notice) was taken at Dewsbury
and District Hospital under Regulation 17 - Outcome 1 Respecting and
involving service users on 31/07/2012
The Trust took immediate swift action to address the areas of concern and reported
to the Care Quality Commission that the actions had been addressed.
In November 2012 an unannounced inspection took place across the three acute
hospital sites which in the main the CQC confirmed evidence of good practice in
relation to the outcomes assessed. Minor concerns were raised in relation to one of
the outcomes which the trust quickly responded to with an action plan.
An unannounced inspection to Queen Elizabeth House Intermediate Care Facility
was reported in March 2013 to be fully compliant with standards inspected against
The Mid Yorkshire Hospitals has not participated in any special reviews or
investigations by the Care Quality Commission during the reporting period
2.2.5 National and contractual quality standards
In 2012/13 Mid Yorkshire Trust has shown significant improvement in the delivery of
the key performance indicators in the operating framework. Annual performance
saw the Trust achieve the required standard in 89% of the key performance
indicators compared to 50% in 2011/12.
2012/13 saw Mid Yorkshire consistently meet all of the access targets: 4 hour
emergency standard, 18 week Referral to Treatment targets and the cancer access
Page 43 of 93
waiting times. Unlike many other Acute Trusts, Mid Yorkshire maintained
performance in the 4 hour emergency standard and the 18 week targets through the
winter period (December 2012 – February 2013). This is particularly impressive due
to the specific pressures that this season brings to hospitals and also when
compared to 2011/12 performance.
The two indicators where the Trust did not meet the required standard in the
operating Framework were:
•
Single Sex Accommodation breaches - The Trust had 4 breaches in 2012/13
against a target of 0, this was an isolated incident which occurred in critical
care areas where mixed sex accommodation is permissible when necessary.
Overall the Trust has seen a 97.4% improvement from 154 in 2011/12 in this
area.
•
MRSA Hospital Acquired Infections – The Trust had 8 infections against a
target of 7. Following Board approved action plans being implemented in
December 2012 there were no reported cases in the 90 day period of Quarter
4, and the Trust year end figure of 8 infections was a 27% improvement from
2011/12.
The Trust’s performance against these targets is shown in the following diagrams:
Page 44 of 93
Compliance Monitoring
Measure
A&E - Total Time in A&E
MRSA
Clostridium difficile
RTT Waiting Times - admitted
RTT Waiting Times - non admitted
RTT Waiting Times - patients on an incomplete pathway
Diagnostic Test Waiting Times
Cancer Two Week Wait+
2 week GP referral to 1st outpatient - breast symptoms+
All Cancers - 31 days wait for second or subsequent treatment - Surgery+
All Cancers - 31 days wait for second or subsequent treatment - Drug+ Treatment+
All Cancers - 31 days from diagnosis to first treatment+
All Cancers - 62 days from screening to treatment+
All Cancers - 62 days from urgent referral to treatment+
Delays transfer of care
Single Sex Accommodation Breaches
VTE Risk Assessment
Page 45 of 93
Annual
Target
2012/13
95%
7
78
90%
95%
92%
<1%
93%
93%
94%
98%
96%
90%
85%
3.5%
0
90%
96.1%
8
39
90.7%
96.3%
93.1%
0.7%
97.9%
97.4%
99.8%
100.0%
99.4%
94.4%
86.2%
2.9%
4
97.9%
April to March 2011/12
% Targets Met
% Targets Not met
50%
50%
April to March 2012/13
% Targets Met
% Targets Not met
11%
89%
Page 46 of 93
Apr-11
Under target
Over Target
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Over Target
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
Over Target
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Apr-11
May-11
Under target
Mar-12
Under target
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
Apr-11
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
Selected Performance Indicators – Demonstrating Progress from 2011/12 –
2012/13
100%
Emergency Department 4hr Performance
98%
96%
94%
92%
90%
88%
86%
84%
Target 95%
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Completed admitted pathways*
Target 92%
Completed non admitted pathways
97.5%
97.0%
96.5%
96.0%
95.5%
95.0%
94.5%
94.0%
93.5%
93.0%
Target 92%
Page 47 of 93
Apr-11
Under target
Over Target
102%
100%
98%
96%
94%
92%
90%
88%
Apr-11
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
Dec-12
Mar-13
70%
Mar-13
75%
Mar-13
80%
Jan-13
85%
Feb-13
90%
Feb-13
95%
Feb-13
100%
Dec-12
Cancer 62 days – urgent rtt for all cancers
Jan-13
Under target
Dec-12
Nov-12
Cancer 2 weeks - referral to OP
Nov-12
Oct-12
Sep-12
Target 92%
Jan-13
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
Over Target
Aug-12
Target 93%
Jul-12
Jun-12
May-12
Apr-12
Over Target
Mar-12
Apr-11
May-11
Under target
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
18 Weeks - Incomplete Pathways
96%
94%
92%
90%
88%
86%
84%
82%
80%
Target 85%
Page 48 of 93
TIA patients scanned & treated < 24 hrs
80%
70%
60%
50%
40%
30%
20%
10%
Under target
Over Target
Mar-13
Jan-13
Feb-13
Dec-12
Oct-12
Nov-12
Sep-12
Jul-12
Aug-12
Jun-12
May-12
Qtr4
Apr-12
Qtr 3
Qtr 2
Qtr 1
0%
Target 60%
Page 49 of 93
Healthcare Acquired C-Diff
120
100
80
60
40
20
0
Apr
May
Jun
Jul
Aug
Sep
C-Diff Target 2012/14
Oct
Nov
Dec
CDIFF 2011/12
Jan
Feb
Mar
CDIFF 2012/13
Healthcare Acquired MRSA
14
12
10
8
6
4
2
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
MRSA 2011/12
MRSA Target 2012/13
Jan
Feb
Mar
MRSA 2012/13
Single Sex Accommodation Breaches
60
50
40
30
20
10
Over Target
Target 0
Mar-13
Jan-13
Feb-13
Dec-12
Oct-12
Nov-12
Sep-12
Jul-12
Aug-12
Jun-12
Apr-12
May-12
Mar-12
Jan-12
Feb-12
Dec-11
Oct-11
Nov-11
Sep-11
Jul-11
Aug-11
Jun-11
Apr-11
May-11
0
Under target
In 2013/14 Mid Yorkshire will strive to improve further by implementing actions that
lead to sustainable delivery and delivery of targets at a granular level.
Patient Safety Dashboard
The Trust is committed to delivering healthcare in a safe environment for our
patients. The Patient Safety Dashboard has been developed to ensure we are
operating to the high standards that are set for us both nationally and that we set
ourselves. The measures that have been included in the dashboard are taken from
the wider Trust Integrated Performance Report.
Page 50 of 93
The dashboard and reporting mechanisms are still under development and this will
be improvement work in 2013/14
:
Page 51 of 93
Patient Safety Dashboard
Ref
Description
1.18a
MYT - VTE Prevention % of adult inpts
who have had a VTE risk assessment on
admission. (also CQUIN)
Exec Project
Lead lead
CL
JH
Mgmt
Forum
11/12 Target Actual
Outturn YTD
YTD
PCMG
Mar 12
97.9%
90%
2012-13 Trend Performance monthly
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
F'cast yr
end
90%
97.9%
97.8%
98.4%
98.4%
98.4%
98.3%
98.5%
98.5%
97.7%
98.1%
97.0%
96.7%
97.3%
97.9%
0
1
1
0
0
1
1
0
0
0
1
2
0
0
1
1
1
3
1
0
1
0
.
7
3
94%
7
8
78
39
1.20a MRSA - reducing infections
KH
SW
DIPC
12
7
8
1.21a C Diff - reducing infections
KH
SW
DIPC
101
78
39
6
7
94%
6
1
94%
6
4
93%
6
5
94%
6
2
94%
6
1
94%
7
5
94%
7
1
94%
7
2
94%
7
3
94%
0
0
.
7
5
94%
RJ
108.4
<100
91.5
<100
102.4
<100
83.5
<100
105.4
<100
86.6
<100
102.7
<100
79.8
<100
92.4
<100
74.8
<100
95.7
<100
98.6
<100
83.0
<100
99.6
<100
91.5
RJ
627
660
551
55
55
55
55
55
55
55
55
55
55
55
55
660
74
48
45
31
32
46
44
60
44
20
43
64
551
2
2
3
1
2
2
3
2
2
1
3
0
2
1
3
1
2
1
3
1
2
0
30
13
3.2a
HSMR - (Relative risk average from Apr
12) (MYHT)
3.3a Medication error rates
3.4a Number of SUIs
3.4b
%age SUI investigations completed on
time (YTD)
.
RJ
18
30
13
3
1
RJ
87%
100%
85%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
78%
100%
78%
100%
80%
100%
82%
100%
83%
100%
85%
100%
85%
100%
85%
3.4c Number of Open SUIs
RJ
N/A
11
N/A
18
N/A
19
N/A
20
N/A
22
N/A
17
N/A
18
N/A
18
N/A
15
N/A
14
N/A
19
N/A
14
N/A
12
N/A
.
3.4d Number of Never Events
RJ
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
3.22a All Category Pressure Ulcers*
KH
294
460
33
33
0%
1
33
37
0%
1
392
460
36
33
47
0%
1
33
28
15
33
44
0%
2
33
40
KH
33
30
0%
2
33
38
3.22a Category 3 or 4 Pressure Ulcers*
33
39
0%
2
1
1
1
18
3.23
Total patient falls
KH
3.23
Number of falls resulting in severe
injury or death
KH
392
2422
9
8
33
33
33
51
34
39
79900% 152000% 226300%
2
2
2
2
1
2
3
1
7
3
1
1
9
5
1
36
224
0%
1
211
0%
1
196
0%
1
208
0%
1
219
0%
1
192
0%
1
191
0%
1
198
0%
1
186
0%
1
205
186
206
2422
1
1
0
11
1
1
1
0
2
0
0
0
1
1
1
0
8
Page 52 of 93
* Target in 2012/13 was to improve from 2011/12 outturn, however during 2012/13 there was a revision in the definition of category of pressure ulcers and also we saw an improvement in data completeness from 65% to 95%.
2.2.6 Patient Advice Liaison Service and the Complaints Service.
Our Patient Advice and Liaison Service (PALS) is available for our patients, relatives
and carers so that they have someone to turn to for on-the-spot help, advice and
information.
The main role of the PALS team is to:
•
•
•
•
Advise and support our patients, their families and carers.
Provide information on NHS services.
Listen to concerns, suggestions or queries.
Help sort out problems quickly on behalf of our patients, carers and relatives.
PALS operates across our Trust and the central Patient Liaison Team works with key
members of staff to provide the best possible service for our patients.
Information on our PALS team can be found on our website at www.midyorks.nhs.uk
Patient Liaison Team
If there are concerns that cannot be resolved by our services then patients, relatives,
carers and visitors can get in touch with a member of our PALS team, who are the
central point of contact for PALS. The team works to get the best resolution for a
complaint or concern and aims to provide a listening ear in order to find the most
appropriate way forward.
During 2012/13, we received 2,700 PALS enquiries to our Patient Liaison Team from
patients, relatives and carers contacting us for practical and emotional support for
their issues or concerns. Working with staff across our Trust, the team also worked
hard to support individuals through the process of making a formal complaint and
ensuring that it was dealt with as quickly as possible.
Throughout the year, the Patient Liaison Team had a particular focus on resolving as
many concerns as possible on an informal basis in order to try and respond more
quickly (as formal complaints can take longer). Much effort was concentrated on
supporting patients in arranging outpatient appointments during January and
February when the Appointment Centre was experiencing difficulties; 300 patients
were assisted during this period.
From 1 April 2013, the team has established a GP liaison service to support
colleagues in primary care requiring advice and help in relation to Trust Services.
The service provided by the Patient Liaison Team is valued both by the Trust and the
community we serve, as demonstrated in the recent ‘blog’ from Stephen Eames our
Interim Chief Executive; “I am delighted to be able to pass on a vote of thanks to a
team who are often on the sharp end when things go wrong – our Patient Advice and
Liaison Service (PALS). A grateful customer sent this email: ‘Someone was in touch
with me within two hours of me emailing PALS and was able to give me the results
and reassure me that everything was fine. Thank you for your assistance in the
matter. If only everything in life could be dealt with so efficiently.’ ”
Page 53 of 93
More information on our PALS team can be found on our website at
www.midyorks.nhs.uk
Compliments and complaints
Formal complaints
We always aim to provide the best possible care for our patients but occasionally
things can go wrong, which is why we take complaints very seriously and investigate
them fully. If there are issues identified, we work with the patient and their family to
address them and learn from them for the future.
We would like to know when things go wrong so we can quickly put them right and
improve our services. If our patients feel unable to discuss their concerns directly
with our staff and wish to formally complain, they can do this by contacting our
Patient Liaison Team on 01924 543685/6/7/8.
More information on formal
complaints can be found on our website at www.midyorks.nhs.uk
We are pleased that, in recognition of the dedication and hard work of our staff, we
continued to receive significantly more compliments than complaints during the year.
Number of compliments
Number of formal complaints received
% acknowledged within three working days (target
100%)
% responded to within the agreed timeframe (target
85%)
Number of referrals to the Ombudsman
Number of PALS enquiries
2011/12
3,090
1,341
81%
2012/13
1,999
1,411
99%
63%
69%
10 (1 upheld)
2,400
16 (1 upheld)
2,700
During 2012/13, as a result of feedback from our patients, carers and relatives, we
made some key changes including:
•
•
•
•
•
The introduction of weekly ‘control tower’ meetings involving clinicians, managers
and waiting list teams to ensure that patients are seen in accordance with their
clinical priority and within the timeframe stipulated by their consultant.
Improvements to the environment and admission procedures for day surgery
patients attending Gate 40 at Pinderfields to enhance the patient experience and
streamline the treatment pathway.
Investment, in terms of increased staffing, and the introduction of new technology
in the Appointment Centre at Pinderfields to address significant problems being
experienced by patients when trying to arrange appointments.
The commissioning of a review of the management of the outpatient service
across the Trust to address identified problems with processes, including the
application of partial booking and the access policy.
The introduction of arrangements within ophthalmology to offer routine review
appointments for Wakefield district residents at local health centres. This
Page 54 of 93
initiative provides care at convenient locations for patients whilst freeing up
capacity within the hospital outpatient clinics.
Our philosophy for handling complaints
The Trust Policy on dealing with formal and informal complaints was reviewed in
September 2011. The Policy outlines our philosophy for handling complaints and
describes how this is underpinned by the Ombudsman’s Principles of Good
Administration, Principles for Remedy and Principles of Good Complaint Handling.
A particular focus for our Trust is the application of the Principles:
• Getting it right
• Being customer focused
• Being open and accountable
• Acting fairly and proportionately
• Putting things right
• Seeking continuous improvement.
2.2.7 Data Quality
The Trust has an Information Governance and Security Management Group which
the Caldicott Guardian attends and influences. In accordance with the Caldicott
Guardian manual this is a position held by a senior clinician.
The Trust accepts responsibility for providing good quality information to underpin
effective patient care, and has monitored standards of data quality throughout the
year at the Management Board chaired by the Chief Executive.
There are documented procedures in place for all statutory returns produced from
within the Trust and reports are validated by the relevant managers in the Clinical
Service Groups prior to submission.
The Trust is continually promoting the use of the summary care records (SCR) to
trace and confirm patient demographic information. It uses the demographic batch
service (DBS) for batch tracing to trace patients prior to submission of Contract Data
Sets (CDS) to ensure optimum population of demographic information, in particular
patient NHS numbers.
The Trust continues to promote the use of centrally produced data quality
dashboards and key performance indicators (KPIs) to monitor the Trust’s progress
towards the collection of key demographic data items. This data is shared externally
with PCTs, the SHA and other external organisations. These are discussed with the
PCT at regular monthly meetings. This is the principle method of data quality
assurance used throughout the Trust so that the Trust can assure itself against
regional and national standards and targets.
Data on ethnicity and other equality data have been monitored by the Trust Board
and can be found in the integrated performance report. During 2012/13, the Trust
was reporting a consistent 94% completeness (against a target of 85%) of ethnic
coding and receipt of a full range of workforce data.
Page 55 of 93
The Trust confirms that it submits returns to the secondary uses system. In the
context of monitoring NHS number usage and validity of General Medical Practice
Codes, Mid Yorkshire submitted records, during April 2012 to February 2013, for
inclusion in the hospital episode statistics which are included in the latest published
data. The percentage of records in the published data with valid NHS numbers is as
follows:
Table 7 – Valid NHS number (data quality)
Patient type
Admitted patient care
Outpatient care
Accident and
emergency care
Mid
Yorkshire
% Target
2012/13 (Apr 11 to Feb
13)
99.7%
99%
99.7%
99%
98.4%
99%
Table 8 – Valid General Medical Practice code (data quality)
Patient type
Admitted patient care
Outpatient Care
Accident and
emergency care
Mid
Yorkshire
2012/13
(Apr 12 to Feb 13)
100%
100%
100%
% Target
99%
99%
99%
Information quality and records management is assessed using the information
governance toolkit which provides an overall assessment of the quality of data
systems, standards and processes. The toolkit is completed by specialists advising
the Information Governance and Security Management Group and validated by
Directors before submission. The Trust’s score for secondary use assurance for data
quality was 87% for the period 2012/13 which is an improvement on 2011/12 when
the score was 83%.
Overall the Trust achieved a score of 85% an improvement on the previous year’s
score of 79%. The trust scored level 2 on all requirements, achieving an overall
satisfactory status.
In order to sustain or improve this score, several initiatives mentioned earlier
continue to take place in line with the Trust’s data quality strategy. These include
audit of record keeping standards, audit of the safe merging of duplicate patient
records, ensuring that when care processes change any adverse impact on
information quality is formally assessed and involving clinical staff in the validation of
data quality.
Finally, for this section on data quality, the Trust is required to report on the quality of
clinical coding. Clinical coding is a process which translates the medical language of
patients’ records into an internationally recognised code which describes the
Page 56 of 93
diagnosis and treatment of a patient. Improving the quality of clinical coding has
been a focus of Mid Yorkshire for the past few years recognising that coding is
central to sound clinical governance and ability to measure the quality of patient
care.
The Clinical Coding Team has been working on delivering a coding improvement
programme to ensure the Trust receives the appropriate income for every episode of
care and also benefit the wider organisation through improving the profile and
credibility of the clinical coding service through effective clinical engagement. To
date, excellent progress has been made in coding improvements.
Key developments / achievements are as follows:A trajectory has been developed to track backlog progress against capacity and
demand. The coding backlog has been reduced from 11,000 in October 2012 to
7,265 to date.
A marked improvement in the HRG error rate can be evidenced from the results of
the PbR 12/13 Assurance Framework Audit for admitted patient care. The report
identified an HRG error rate of 5.1% which places the Trust better than average.
The PbR audit undertaken in 11/12 identified an HRG error rate of 16.5% which
placed the Trust in a worse than average position.
The depth of coding Trust wide has improved from 4.5 in April 2011 to 5.05 in
February 2013.
An Audit and Assurance Framework has been developed which identifies the
principal objectives to achieving high quality data, the risks, the key controls in place
to manage the risks and the assurance required. The Framework also highlights the
reporting mechanism of key information to the control groups.
A suite of Data Quality Reports have been developed in conjunction with the KMS
team. These reports identify coder error and issues with the source documentation
used for coding. These reports are run on a monthly basis. Coding errors are
addressed by the coding trainers and source documentation by the Divisions.
New Key Performance Indicators are being developed to highlight improvements
made through coded data which include:- % data coded at flex, poorly coded
episodes, returns to clinicians, HSMR and palliative care rates and the depth of
coding.
The senior coding team has received training on the Dr Foster database in order to
monitor the HSMR, palliative care rates and the Charlson index rate.
A robust mechanism is now in place to provide assurance that the team capture all
patients who have palliative care input.
The current HSMR rate is 91 with a rebase of 96 in comparison to 108 in March
2012.
Page 57 of 93
It is essential for the quality of the data that there is good communication between
the clinicians as generators of the information, and the coders as the translators.
Clinical engagement and ownership is fundamental to high quality data therefore a
Clinical Engagement Strategy has been developed. The actions include:•
•
•
•
The development of a meeting plan with lead clinicians to address; HSMR issues,
actions arising from the PbR benchmarking tool, source documentation, uncoded
episodes and any other data quality issues relevant to specialty. Attendance is
monitored at the Coding Steering Group along with evidence of actions and
improvements.
Internal and external audit results are shared with the clinical teams and patient
services managers to highlight areas of concern. Action plans are developed to
address coding and clinical information issues.
The introduction of a programme of coding validation between clinician and coder
for each specialty. Priority areas are identified utilizing the PbR benchmarking
tool. This is an incremental programme until a full staffing establishment is in
place.
An annual training prospectus for the internal teams and clinicians has been
developed following a training needs analysis for the coding team. Meetings will
be held with the specialty leads to plan and deliver training / awareness sessions
for clinicians.
A RPIW (Rapid Process Improvement Workshop) was undertaken in April 2013 to
make both internal and external processes leaner thus improving the timeliness of
coding.
This year as per the Quality Account Guidance the Mid Yorkshire Hospitals Trust is
required to report on a core set of indicators.
Trust is only required to report on the indicators relevant to the services that they
provide. A table of those key indicators with the current data are provided below.
Page 58 of 93
Domain
Preventing people
from dying
prematurely
Helping people
recover from
episodes of ill health
or following injury
Ensuring that people
have a positive
experience of care
Treating and caring
for people in a safe
environment and
protecting them from
avoidable harm
Treating and caring
for people in a safe
environment and
protecting them from
avoidable harm
*
**
***
****
*****
******
Quality Indicator
SHMI value and banding (April 2012 –
June 2012)*
% of admitted patients whose treatment
included palliative care (April 2012 –
March 2013)*
% of admitted patients whose deaths
were included in the SHMI and whose
treatment included palliative care
()*
Patient reported outcome scores for
groin hernia surgery: Unadjusted
Healthgain Score
(April – September2012)*
Patient reported outcome scores for
varicose vein surgery (April – October
2011)*
Patient reported outcome scores for hip
replacement surgery Unadjusted
Healthgain Score
(April – September2012)*
Patient reported outcome scores for
knee replacement surgery Unadjusted
Healthgain Score
(April – September 2012)
Responsiveness to inpatients' personal
needs: CQC national inpatient survey
score******
Percentage of staff would recommend
the provide to friends or family needing
care*****
% of admitted patients risk-assessed
for Venous Thromboembolism
(April 2012-March 2013)**
Rate of C.difficile per 100,000 bed days
(2011/12)***
Rate of patient safety incidents per 100
admissions
(April 2012 – September 2012)****
% of patient safety incidents reported
that resulted in severe harm of death
(April 2012 – September 2012)****
The percentage of patients aged 0-14
and 15 and over, readmitted to hospital
which forms part of the Trust within 28
days of being discharged from a
hospital which forms part of the Trust
2012/13
100.6
Defined as 100
2.6% of the
HSMR
bundle of
diagnoses
2.6%
2.5% of the
HSMR bundle of
diagnoses
0.134
0.090
No data
0.089
0.417
0.429
0.286
0.321
66.5
68.1
41.4%
63.3%
97.9%
94.1%
27.3
21.8
3.7
6.2
0.36%
<1%
(0-14) 6.3%
Please see
comments on
following page.
>15 yrs
7.7%
Information obtained from the NHS Information Centre website
Information obtained from the Department of Health
Information obtained from Health Protection Agency
Information obtained from the National Patient Safety Agency
Information obtained from the NHS Staff Survey 2012 Results
Taken from Dr Fosters PPM Tool
Page 59 of 93
National
Average
102
The percentage of patients aged 0-14 and 15 and over, readmitted to hospital which
forms part of the Trust within 28 days of being discharged from a hospital which
forms part of the Trust.
• The data provided in the 12/13 column for this indicator is from Dr Foster.
Unfortunately we do not have access to the national position on Dr Foster split
by age. The national average for all age groups from Dr Foster is 6.7% and
the MY rate 7.5% for all ages.
• Alternatively data is available from the HSC Information Centre which
provides a national average position and split by age groups. Unfortunately
the age groups differ slightly from those identified in the table above and are
for <16yrs and >16 yrs. Also the latest data available is for 2010/11. The data
for these is below:
o <16 yrs: 9.31% (MY), 10.15% (National)
o >16yrs: 11.85% (MY), 11.42% (National)
Page 60 of 93
Part Three: Other Information
At the end of 2011/12 we set out our quality priorities for 2012/13 and how we
intended to achieve those aims. The following section sets out what those priorities
were, how we addressed them and how successful we were in achieving those aims.
3.1 Quality priorities for 2012/13
Priority 1
Improve
systems and
processes to
further reduce
mortality rates
Lead: Associate
director –
Clinical
Governance
When HSMR (nationally) is benchmarked
against 2008 data, there has been a national
fall from 100 to 74. At Mid Yorkshire it has
fallen to 80, although it started at 113. During
2012/13 we addressed this by:
•
•
Sponsor:
Medical Director
•
•
•
Target achieved:
HSMR 96 below
the national
average
Improving palliative care coding. Last
year coding fell from 94% of national
average to 58%. Good palliative care
coding increases the number of
expected deaths and reduces HSMR.
Continuing the monthly mortality and
morbidity meetings and use the global
trigger tool to explore the standards of
care and opportunities for
improvement.
Exploring every trend in data and
report to the QCGC.
Triangulating, through the patient
safety panel meetings, data from the
Safety Thermometer, mortality and
morbidity meetings and audit of
cardiac arrest calls to inform our
understanding of care processes.
Establishing a task and finish group to
report in September on the precise
factors affecting HSMR.
Priority 2
The NHS Safety Thermometer is for
Target achieved:
measuring, monitoring and analysing patient
Improve patient harms and harm free care. During 2012/13 Harm free care –
we addressed this by:
safety by
85%
implementing
the Safety
• Using the Safety Thermometer each Reduction in fallsThermometer
month from April 2012.
1.07%
• Publishing the results of the Safety
Thermometer in the Chief Nurse
Lead: Deputy
Reduction in
quality report to the Trust Board.
Chief Nurse
pressure sores• Triangulating the results of the Safety 3.18%
Thermometer with the nurse sensitive
Sponsor: Chief
indicators and point prevalence
Nurse
studies and create a ward / community
Page 61 of 93
•
dashboard to ensure that monitoring is
in place across the whole Trust.
Taking appropriate and timely action
on the results of the ‘safety
temperature check’.
Priority 3
Locally, by 2025 the projected increase in the
number of people aged over 65 years and
living with dementia is expected to increase
Improve the
diagnosis and by 58%. In 2010, hospital episode data
care of patients informs us that 146 people were admitted to
with dementia our hospitals in Mid Yorkshire with a primary
diagnosis of dementia. During 2012/13 we
Lead: Associate addressed this by:
Director of
• Participating fully as active members
Nursing
of the multi agency dementia board.
(medicine)
• Screening patients using a
standardised assessment tool,
Sponsor: Chief
including a pilot of screening (patients
Nurse
over the age of 75 years) care of the
adult community nursing service.
• Developing pathways for dementia
and delirium and include guidance on
the use of anti-psychotic medications.
• Ensuring that staff have the required
knowledge and skills to care for
patients with dementia, and identify
dementia champions.
• Participating in the national dementia
audit.
• Developing patient held information
that can be used by all agencies
involved in supporting the patient and
family.
• Reviewing end of life care plans to
ensure that they are sensitive to the
needs of a patient with dementia.
Page 62 of 93
The Trust has
continued to make
progress on
implementing the
strategy
Demonstrated
improvements in
the national
dementia audits
Priority 4
The incidence of hospital acquired MRSA
Target not
bacteraemia has decreased year-on-year for achieved:
the past five years. It was our aim to achieve
Improve
compliance with fewer than seven cases in 2012/13 we
MRSA cases – 8/7
addressed this by:
best practice
guidelines and
Target achieved:
prevent
• Expecting primary care to account for
healthcare
achieving good practice community
C.Diff cases –
acquired
suppression therapy and monitor
39/78
through the executive quality board led
by commissioners.
infection*
• Positively treating patients with known
MRSA colonisation differently, e.g.
Lead: Director
limit the number of people able to
of Infection
make decisions to insert invasive
Prevention and
devices (other than in an emergency)
Control (DIPC)
and limit the range of people able to
prescribe particular drugs to patients
Sponsor: Chief
known to have MRSA on the skin, in
Nurse
the nose or in wounds.
• Ensuring that all staff involved in
inserting devises are trained in aseptic
non-touch techniques (ANTT).
• Holding daily telephone conferences
lead by the DIPC to ensure that all
relevant staff know precisely which
patients are colonised and need
enhanced high level precautions.
• Ensuring that clinical staff are informed
within one hour of the laboratory
having results of colonisation or
infection.
In addition, the incidence of C Difficile
infection has decreased significantly over the
past three years and the 2012/13 target was
no more than 78 cases. To achieve this we:
•
•
Relentlessly pursued antibiotic
stewardship.
Closely monitored cleaning standards
and through the annual environment
audit ensure that all inpatient wards
achieve 95% compliance with
cleanliness standards.
Page 63 of 93
Priority 5
In 2010/11, the Trust twice cancelled and
rescheduled more than 7,000 outpatient
appointments. For that reason a reduction
Improve
target was set and included in the 2011/12
outpatient
Quality Account. We failed to make any
scheduling,
impact and twice cancelled and rescheduled
bookings and
communications as many outpatient appointments in 2011/12.
During 2012/13 we addressed this by:
with patients
Lead: Chair of
the Integrated
Care Division
•
•
Sponsor: Chief
Operating
Officer / Deputy •
CEO
Target not
achieved:
8.7%
Target 50%
% clinics cancelled
Reviewing all elements of productivity with
an early focus on do not attend rates and
follow up rates
Reviewing the content of patient letters
and measure patient experience18 at
least quarterly
Implementing an effective performance
framework which includes:
o
o
o
o
Key performance measures
Unambiguous lines of
accountability and levels of
authorised delegation
Appropriate engagement with the
Local Involvement Networks
(LINks)
‘Service to contract’ reporting
Detailed achievement against priorities for 2012/13:
3.1.1 To improve systems and processes to further reduce mortality rates
Measurement of mortality is an important part of assessing the safety of hospitals
and this has been the focus of a lot of attention following the Francis reports into the
issues raised by events at the Mid Staffordshire Hospitals’ NHS Foundation Trust.
There are a number of different ways that mortality can be measured. It is not useful
to compare actual death rates between hospitals as the severity of illness and types
of cases seen can vary so a number of measures have been developed to correct for
these types of differences by producing ‘standardised’ mortality rates.
The two best known of these are the Hospital Standardised Mortality Rate (HSMR)
produced by Dr Foster and the Summary Hospital-Level Mortality Indicator (SHMI)
produced by the Department of Health. The main differences between the two
measures are that the HSMR takes into account palliative care coding (managing
pain in terminally ill patients) and is limited to the 56 diagnosis groups that are
responsible for about 75% of hospital deaths whereas the SHMI doesn’t include
allow for palliative care coding and includes all deaths.
Page 64 of 93
Main differences between HSMR and SHMI
HSMR
SHMI
Deaths in hospital only
Deaths within 30 days of hospital
discharge
Includes 80% of hospital deaths
Includes 100% of hospital deaths
Affected by palliative care coding
Not affected by palliative care coding
The HSMR for the Trust in 2011/12 was 108.2 which was significantly higher than
the expected rate. We undertook a lot of work to understand why the HSMR was
high and found that the main reason was that we had under reported the proportion
of patients who were having palliative care. We were only reporting about 60% of the
rates that the average Trust reported. Dr Foster confirmed that this was the main
factor.
During 2012/13, we did a lot of work to improve our mortality rates by focussing on
the quality of care, on the types of patients coming into hospital and on ensuring we
were coding properly. Some of the actions that we took were:
• Working with our partners to extend hospice admissions to 24/7 and to
increase palliative care support to people at home. This allowed more people
to die in their place of choice rather than dying in hospital.
•
Launched a revised care process for recognising and treating sepsis (severe
infections) using a care bundle that emphasised earlier antibiotic treatment
and better supportive care.
•
Implemented mortality reviews in specialties and a twice yearly Trust wide
mortality review
•
Introduced a revised weekly Patient Safety Panel to rapidly respond to any
safety concerns and to implement rapid changes when needed using a
weekly Patient Safety Bulletin for all staff.
•
Ensuring we correctly coded information about patients’ care.
During the year we have seen a progressive fall in the HSMR so that the rebased
level after the first 10 months of the year is now below the national average at 96
(see figure below).
Page 65 of 93
Rebased HSMR for April 2012-January 2013 (data from Dr Foster)
Each grey dot represents a hospital Trust and the large marker is Mid Yorkshire
Hospitals.
The SHMI data is published six months after the period it applies to so we don’t yet
have the full results for 2012/13. The table below shows the quarterly SHMI results
for 2011/12 and the first two quarters of 2012/13.
SHMI data by quarter for 2011/12 and 2012/13
Year
2011/12
2012/13
Quarter Q1
Q2
Q3
Q4
Q1
Q2
SHMI
102.0 98.9 105.0 108.6 100.6
Naturally, every death which occurs is a personal tragedy for the individual and those
that care for them but we are pleased and heartened by the reduction in rates that
we have achieved and are confident that we can continue this reducing trend.
Palliative care coding
The data shows the percentage of patient deaths in hospital with palliative care
coded at either diagnosis or specialty level. This denotes that the patient had clinical
input from a specialist palliative care team before their death. In some mortality
measures, this is taken into account in the standardisation, making the assumption
that a patient who has had palliative care input should not be classified as an
unexpected death. A proportion of people who die in hospital will receive palliative
care input but the recording of this varies widely between hospitals.
Page 66 of 93
3.1.2 To improve patient safety by implementing the Safety Thermometer
The Safety Thermometer was introduced into the Trust in April 2012. Data is
collected on the second Tuesday of every month prior to midday from in patient
areas on every patient in a hospital bed.
The Safety Thermometer focuses on the provision of ‘harm free’ care. The definition
of ‘harm free’ care means that patients are not subjected to the following:
o
o
o
o
Pressure ulcers (hospital acquired)
Falls with harm
Catheters and urinary tract infection (UTI)
Venous thromboembolism (VTE)
The monthly data has been reported to board each month in the quality report by the
Chief Nurse.
From the collection of baseline information in April 2012, figure 1 below shows that
the provision of ‘harm-free’ care has increased from 79.96% to 85.00%.
Figure 1. Dashboard from safety thermometer (Percentages)
Page 67 of 93
Figure 2 below displays that all falls (with and without harm) have overall been
reduced by 1.07% during the period April 2012 – March 2013.
Figure 2. Falls with and without harm April 2012- March 2013
Below, figure 3 shows that the number of pressure ulcers has reduced overall during
2012/13. Initially in April 2012, 10.02% of our patients acquired a pressure ulcer
which has reduced to 6.84% in February 2013, a reduction of 3.18%.
Figure 3. Pressure ulcer prevalence April 2012-March 2013
Page 68 of 93
What we did do to improve
•
•
•
•
•
•
IMPACT – improving pressure area care and treatment training programme
and raising awareness across the surrounding health economy in conjunction
with neighbouring trusts and local authorities. Posters, public information
leaflets pocket size information cards have been produced.
.Introduced the new version of the waterlow risk assessment tool this year
with guidance for staff on prevention strategies for the new admission booklet
Training programme in place accessible for staff.
Introduced new alternating cushions across the organisation to ensure that
patients have pressure relief when sat out and whilst in bed with new
additional mattresses purchased.
A new decontamination bay for the cleaning of dynamic mattresses also
opened at the end of last year with processes put into place.
Pressure ulcer panels were introduced and are now led by each division to
review RCA`s for patient that have developed category 3 or 4 pressure ulcers.
Next steps
•
•
•
Tissue viability conference in May 2013 with the theme accountability in tissue
viability
To introduce a system of recording pressure ulcer free days onto ward areas
Further introduce the full skin bundle and consider integrating with intentional
round chart to promote the concept of `think skin`
Patient safety incidents
The data looks at three measures related to patient safety incidents reported to the
National Reporting and Learning System (NRLS).
•
•
•
The rate of incidents reported per 100 admissions. Incident reporting rates
may vary between trusts and this will impact on the ability to draw a fair
comparison between organisations
The number and percentage of reported incidents that resulted in severe
harm to a patient/s.
The number and percentage of reported incidents that resulted in the death of
a patient/s.
MYHT’s latest published scores are below the national average for all three
measures.
MYHT considers that this data is as described for the following reasons:
•
•
•
The data is collated by front line staff in relation to patient safety incidents
There is a robust policy and process within the Trust to ensure that all
incidents are identified, managed, reported and investigated in accordance
with national guidance
The Trust ensures that there are appropriate measures in place to prevent
recurrence and also promotes organisational learning.
Page 69 of 93
MYHT has taken the following actions to improve this score and so the quality of its
services, by:
• Promoting patient safety as a key objective across the organisation and
implementing a number of mechanisms to ensure compliance with, and
delivery of national frameworks for example the Patient Safety First initiative
• There is a continual focus on quality at an organisational, Directorate and
front line level through a variety of structures, for example, Quality
Governance Groups at Corporate and Directorate level, Patient Safety Visits,
Weekly/Quarterly Monitoring Reports, route cause analysis (RCA)
investigation groups.
In addition the Trust can report an updated position up to September 2012 with data
supplied by the NHS Commissioning Board. MYHT’s reporting rate between 1 April
2012 and 30 September 2012 was 3.7 incidents reported per 100 admissions.
Incidents reported by degree of harm in this period were five graded as severe, and
five that resulted in death. Of the incidents that resulted in severe harm or death,
five were investigated as serious untoward incidents, and actions to address the
findings put in place, and one was a result of recognised complications and
investigation revealed that no further action was needed.
3.1.3 To improve the diagnosis and care of patients with dementia
The Department of Health published the National Dementia Strategy in 2009, the
focus of which was to look at the support and services which people with dementia
and their carers receive for within the United Kingdom.
Locally, by 2025 the projected increase in the number of people aged over 65 years
and living with dementia is expected to increase by 58%. Improving the diagnosis
and care of patients with dementia is one of the five key priorities for the Mid
Yorkshire NHS Trust.
As a result the Trust has signed up to the national register of Dementia Friendly
Hospitals and committed to be an active member of the multi agency dementia
board, working with the local authority, mental health trust and other agencies to
agree priorities and action plans.
We have recently participated fully in the second National Dementia Audit, and the
results show we have made significant progress in developing policies and
developing ward level Dementia Champions. Our training programme on dementia is
in place and staff now have the opportunity to gain additional knowledge and skills to
care for patients with dementia.
We have commenced screening patients over the age of 75 years for dementia and
have guidance for staff in place to investigate and support those identified. We are
currently developing patient held information that can be used by all agencies
involved in supporting the patient and family, and reviewing end of life care plans to
ensure that they are sensitive to the needs of a patient with dementia.
Page 70 of 93
As part of supporting the carers of those with dementia the Trust will be analysing
complaints made where the patient in question has dementia and sending out a
questionnaire on level of support to carers of those patients with dementia.
Improving the diagnosis and care of patients with dementia was included as one of
the five key priorities for the Trust to be measured against for 2012-13. In the
following paragraphs we explain in detail the key measurements of how this has
been achieved and monitored to ensure that measurable improvements for patients
within the Trust who have dementia.
Participate fully as active members of the multi agency dementia board
The Wakefield Multi-agency Dementia Board continues to drive the partnership
priorities against the national dementia agenda and holds strategic accountability for
the delivery of the local plan through its partners. Mid-Yorkshire Hospitals Trust
contributes equally to that partnership arrangement and supports the ongoing joint
appointment of a project manager.
This post will be supported for a further year to work with the Trust and other
partners to continue to dive forward and support the key priorities and delivery of the
change agenda for dementia across the Wakefield area. Key linkages to the wider
economy within Kirklees are also supported through this relationship
Shared initiatives include local opportunity to sign up to the national Call to Action for
providing Dementia Friendly Hospitals alongside Dementia Friendly Communities,
which is one of the priorities for the Board
Screen patients using a standardised assessment score, including a pilot of
screening (patients over the age of 75 years) care of the adult community
nursing service
Through the implementation of the Dementia Care Pathway across the Trust, the
use of a standardised screening score has been implemented within both acute and
community (ACN) services.
The use of the 6CIT (Cognitive Impairment Test) has been agreed as the standard
assessment score of choice within the Trust and guidance on the use of the score is
incorporated into the pathway document. The National Dementia Audit results which
are due in February will provide feedback on performance against this and inform the
Trust action plan going forward
Develop pathways for dementia and delirium and include guidance on the use
of anti-psychotic medications
•
The Dementia Steering Group members have developed pathways for
patients with dementia and delirium. These pathways utilize the most relevant
policies and guidance which are available on these conditions. NICE Clinical
Guideline 42 – Dementia: supporting people with dementia and their carers in
health and social care (including anti-psychotic medications), Clinical
Guideline 103 on Delirium and the Dementia Quality Standards.
Page 71 of 93
•
Pilot audits have been completed within the clinical area of two wards within
Pinderfields General Hospital and Dewsbury District Hospital. The pathways
amended accordingly following feedback from these areas ensuring that these
pathways are user friendly and fit for purpose. Both pathways have now been
implemented within all clinical areas and are available on the dementia web
page on the Mid Yorkshire Intranet.
•
A further audit is planned to be undertaken in March 2013 to evidence the
impact following the implementation of these pathways.
•
Pinderfields General Hospital and Dewsbury District Hospital have
participated in the 2nd round of the regional antipsychotic audit, funded by the
Department of Health and the NHS Yorkshire and Humber with the support
from the Regional Dementia Board. The aim of the audit is to accelerate
improvements in local practice in prescribing anti-psychotic drugs for people
with dementia. Data analysis is being completed by the NHS Yorkshire and
Humber SHA and a report should follow with results and recommendations.
•
A review of tools and guidance is anticipated through the audit once the
results and report is received.
•
Pharmacy staff at ward level to monitor and check with doctors why patients
are prescribed antipsychotics on discharge and ensure reviews are
completed.
•
A letter will be sent out to all Trust consultant’s from the dementia lead to
remind them of the importance of completing antipsychotic medication reviews
on their patients.
Ensure that staff have the required knowledge and skills to care for patients
with dementia, and identify dementia champions
• Work is ongoing with the assistance of Organisational Development to
develop information which staff can access easily at all times throughout a 24
hour period.
• E-Learning package developed and agreed
• Package is available on the Trust Intranet site for all staff to access within
clinical and non-clinical areas
• Targets set for which staff and areas require the training first due to the
patient cohort that they have within their environment and which would have a
greater impact on ensuring that staff has the required knowledge and skills for
management of patients with dementia.
• E-Learning target prioritised for the following group of staff with roll out
completed by the end of April 2013
1. Dementia Champions
2. Elderly Wards
3. Acute Assessment Areas
Page 72 of 93
•
•
•
Surgical Assessment 36 Dementia champions have been identified and all will
complete the identified e-learning and ongoing training schedule covering the
Trusts policies and processes, challenging behaviour and discharge, end of
life and advanced care directives and The Mental Capacity Act, deprivation of
liberty and the role of IMCA.
A pilot environmental assessment is being undertaken on the acute
assessment unit at Dewsbury. Feedback from this will indicate changes that
could be made to make the acute wards more dementia friendly along with
larger scale projects that could be considered.
Reviewing of environments will become a focus of the dementia champions to
ensure it meets the needs of patients and carers
Participate in the national dementia audit.
The Trust has participated in the National Audit of Dementia 2012. This consisted of
two modules.
•
•
Organisational Questionnaire
Case Note audit
For the case note audit, which both Pinderfields Hospital and Dewsbury District
Hospital participated in, the records of a minimum of 40 patients with a diagnosis or
current history of dementia were audited against a checklist of standards that related
to their admission, assessment, care planning/delivery, and discharge. The data was
completed in the agreed timeframe and the numbers of proformas submitted were:
•
•
Pinderfields Hospital 25
Dewsbury District hospital 25
The National report will be published in June 2013.
The Trust has also participated in the Regional Anti-psychotic Medication Audit
which is being managed by the NHS Yorkshire and Humber Strategic Health
Authority. The figure submitted is the same as the National Dementia Audit for both
hospitals.
Develop patient held information that can be used by all agencies involved in
supporting the patient and family.
A scheme is underway led by the steering group and linked to the wider community,
to highlight vulnerable patients on wards with a ‘Forget-Me-Not’ logo which will be
incorporated onto a range of materials for use by patients carers and staff along with
patient information cards which will provide staff with vital information to aid in
understand the patients individual needs and provide a more person centred
approach to care during their stay in hospital.
A pilot of the materials will be undertaken to ensure that they are appropriate to the
needs of patients as described and amendments made prior to wider circulation. We
are also hoping to work further on the forget me not campaign on specific wards and
we have audited the environment with regard to the journey for patients with
dementia i.e. coloured crockery and decoration.
Page 73 of 93
Review end of life care plans to ensure that they are sensitive to the needs of a
patient with dementia
The care plans and advanced care planning approach to end of life care across
hospital and community is led by the palliative care teams and incorporates the
specific requirement to ensure that dementia patients are identified and provided
with relevant information and choices at end of life where possible or their carer on
their behalf where this is not possible. Data collection had started within the teams to
record;
•
•
Whether or not the patient was able to engage in the Advanced Care
planning process
If not who was engaged on their behalf
This data should be able to be reported quarterly going forward from this process
and will enable further data to be added and evidence the engagement of dementia
patients.
They will also be engaged in the rollout of the ‘Amber Bundle’ which will link to the
Care Pathway for the Dying and support the concept of forward planning and choice
at an earlier stage. ‘Time to Talk’ leaflets are also being adapted and devised in
conjunction with the End of Life facilitator which incorporate information and
signposting, for patients, families and carers relating to support, finance, equipment
and options for the future.
3.1.4 To improve compliance with best practice guidelines and prevent
healthcare acquired infection (HCAI)
The Trust failed to achieve our MRSA bacteraemia target in 2012/13 but achieved a
27% reduction in MRSA bacteraemia on the previous year’s performance and we
achieved the C.Difficile target by a reduction of 61% in reported infections.
Graph showing HCAI on a site-by-site basis:
25
20
Cases
15
10
5
0
Dewsbury
MRSA Bacteraemia (Post 48) Hour
2
Clostridium Difficile (Post 72) Hour
18
20
Pinderfields
6
Pontefract
0
1
Total
8
39
Page 74 of 93
MRSA
The root cause analysis process was rigorously applied in all 8 cases by the infection
prevention and control team and all findings were reported to the Trust Executive
Directors who:
•
Analysed the care to identify areas of good practice, identify areas of poor
practice and plan appropriate measures to prevent further patients developing
infections.
•
Clarify accountability for practice
•
Determine if the case was avoidable or unavoidable.
Clostridium Difficile
We achieved our Clostridium Difficile reduction target by a substantial margin as
shown by the graph below which indicates that against a target of no more than 78
cases we had only 39.
Our strategy
We continue to tackle healthcare acquired infection rates by using the Infection
Prevention and Control Committee which is currently chaired by the Chief Executive
and attended by clinicians representing each of the Clinical Divisions, a
representative of the Director of Public Health, Occupational Health, the Medical
Director’s office and the Chief Nurse/DIPC, to review performance, advise on policy
and approve action plans on a monthly basis.
We have also:
• Recruited a new member to the infection prevention and control team with
specific responsibility for hand hygiene who has developed a hand hygiene
competency tool for clinical staff
•
The infection prevention and control team follow up all patients diagnosed with
MRSA and C.Difficile and provide support to the clinical team.
•
Trained clinical staff in the taking of blood cultures. In order to improve the quality
of blood cultures and reduce the contamination rates, several initiatives focused
on all the steps involved in blood culture taking. Information materials were
included in blood culture packs.
•
Trained staff on the clinical indications of taking blood cultures and the
appropriateness of requesting them was initiated both face to face in drop in
sessions as well as by a video made available on the Intranet. In addition, a “pop
up” box on ICE system is a reminder of the indications on taking blood cultures.
•
Developed the weekly MRSA burden data and are able to identify the rate of
hospital acquisition and undertake an analysis of this to prevent further hospital
acquired
Page 75 of 93
•
Commenced monthly audits on antibiotic prescribing on the ward across the
Trust
•
Introduced a Cannulation e-learning package
•
Developed training and care pathways for patients with central venous access
devices in situ
•
Established a discharge bed space cleaning standard- working with our Private
Finance Initiative (PFI) providers
We have also worked with colleagues within the health economy to provide:
•
Timely decolonisation treatment for patients who are diagnosed with MRSA after
discharge
•
A catheter care record for all patients within the health economy a catheter care
record
•
All patients diagnosed with MRSA of C.Difficile, an MRSA/C.Difficile card to
present whenever they access healthcare.
Whilst it is disappointing not to have achieved our MRSA target this year we are
confident that we can continue the downward trajectory of infection and fully expect
to achieve our target of zero tolerance of healthcare acquired infection in 2013/14.
3.1.5 To improve outpatient scheduling, bookings and communications with
patients
Our fifth quality priority in 2012/13 was to improve the scheduling of outpatient
appointments, reduce cancellations and improve communication with patients. This
was a priority area that we failed in 2011/12 therefore we wanted to ensure that we
did make improvements this year. We know through complaints that this was an area
of frustration for the public especially regarding the rescheduling of outpatient
appointments and understand the negative impact that this has on patient
experience and quality of care. Therefore in the summer of 2012 the trust launched
its outpatient improvement programme overseen by a project manager the
programme had a strong project structure agreed indicators and performance
management system.
The following are some of the key areas the programme focused on
•
•
•
•
•
•
Cancellation and rescheduling of clinics
Appointment slot issues
Utilising choose and book
Reducing waiting times for first appointment
Reduce complaints thereby improving patient satisfaction
Improve access for patients to OPD appointment centre
Page 76 of 93
What has been achieved
•
•
•
•
•
Cancelled appointments under 42 days have fallen from 4011 in August 2012 to
2320 in December 2012, a fall of 42%.
Fallow clinics have been created
The number of long waiters is now reducing and improving
Improved telephone access and complaints now reducing
Developed a communication plan
Good progress has been made against a number of the priorities the reduction in
appointment slot issues reduction in cancellation of appoints and the improved
access via the telephone system are encouraging.
The Trust will continue to work on improving waits for the 1st OPD appointment.
Therefore this work is included as one of the five priority improvements areas in the
TDA operating plan for 2013/14.
Page 77 of 93
Outpatient Efficiency KPI Dashboard 2012/13
Indicator
Description
Percentage of
appointments
cancelled < 42
days notice
Percentage of
clinics
cancelled (or
reduced) with <
42 days notice
Target
Baseline
2011-12
5%
9%
11.1%
Apr12
May 12
Jun12
Jul-12
Aug12
Sep12
Oct12
Nov12
Dec12
Jan13
Feb13
Mar13
YTD
201213
7.7%
9.2%
10.6%
9.3%
10.5%
9.7%
8.7%
7%
7%
7%
8%
9%
8.7%
8.0%
8.5%
4.4%
4.0%
6.4%
6.7%
6.6%
5.8%
5.2%
6.5%
2.7%
1.3%
5.5%
Page 78 of 93
Percentage
Total Services
Total In PB
Total To Go PB
Total Not to Go PB
25
16 64.0%
5 20.0%
4 16.0%
Percentage
Total Proposed PB 21
Currently PB
16 76.2%
Future PB
5 23.8%
Services in Partial
Booking (PB)
Partial Booking (PB)
Total In PB
16%
Total To Go PB
20%
64%
24%
Total Not to Go
PB
Page 79 of 93
Currently PB
Future PB
76%
•
•
•
•
•
Deployment of ‘partial booking’ - a system where patients are required to
call in and agree a date, which reduces non-attendance and increases
outpatient efficiency. Partial booking established in 76.2% of specialties,
remaining to commence in Q1 2013/14
Implemented telephone remind systems: Patients who do not attend their
outpatient appointments across the NHS cost millions of pounds each year.
This in turn has an impact on waiting times and in some instances over
booking clinics to account for the people who do not attend their
appointments. This can then cause overcrowding of waiting rooms when a
majority if not all of patients attend. This can lead to a poor patient
experience and possibly even complaints.
To help alleviate this problem the Trust acquired the Remind+ System. The
system is an automated telephone system that rings patients 7 days before
their appointment to remind them when their appointment is. The system will
give the patient the option to confirm attendance, rebook their appointment or
to cancel their appointment.
The aim of the system is to reduce the Did Not Attend (DNA) rate which leads
to freeing up appointment spaces that would otherwise be wasted. A further
benefit is that if a patient cancels or wishes to rebook the appointment, the
slot that was originally allocated can be offered to another patient.
Provided training for call centre staff on customer care: Customer care
NVQ level 2 has been undertaken by all staff within the call and administrative
centre of the outpatients department through 2011/12. Additionally the staff
have undertaken NVQ level 2 in business within 2012. New starters to the
department (apprentice staff) undertake this training with the support of MYHT
and Wakefield Collage.
We are confident that as these measures continue to be rolled out into 2013/14 we
can continue to provide a more patient satisfactory and effective outpatient
appointment scheduling service and we are pleased with our progress against this
priority in 2012/13.
Annexes 1. Comments received on the quality account
2. External audit report
Quality Account 2012-13
Statement from Wakefield Social Care and Health Overview and Scrutiny
Committee
The Social Care and Health Overview and Scrutiny Committee as engaged with the
Trust to review and identify quality themes and issues that members believe should
be both current and future priorities. This has included a specific meeting with the
Trust on progress against the areas of improvement identified in the 2011/12 Quality
Account and suggested areas for improvement to be included in the 2012/13 Quality
Account. This allowed consideration of any potential issues that may have been of
concern and has helped the OSC build up a picture of the Trust’s performance in
relation to the Quality Account.
On the basis of this dialogue and engagement, together with the wide range of
stakeholder involvement, the Committee is assured that the identified priorities are in
concert with those of the public.
The Committee accepts the statement from the board, which underscores the
organisational focus on improvement, and agrees that the Quality Account reflects
accurately performance against a set of selected quality indicators.
It is particularly encouraging to see some improvements, specifically in relation to
key performance targets, such as the four hour emergency care standard and 18
weeks referral to treatment. Of particular interest to the Committee is the
improvement in mortality rate, which demonstrates that the Trust has made
considerable progress in providing assurance to patients and the public about the
safety and quality of services.
We know from patient feedback that the Trust is performing well in relation to not rearranging a patients’ admission date, as highlighted in the Inpatient Survey. We also
welcome the Trusty being among the best performers nationally in providing support
for patients in eating their meals.
Feedback from member constituents supports the view in the Inpatient Survey that
the Trust does not compare favourably in terms of overall views and experience, the
perception of not enough nurses being on duty and in providing patients with clear
information on medicines. However, the Committee accepts the survey results need
to be viewed in context of rapid improvements which have been implemented since
July 2012. The Committee will review these areas over the coming year to support
and challenge the Trust to sustain this improvement.
It is disappointing to note that the target set in 2012/13 in relation outpatient
scheduling, bookings and communications with patients was not met.
The
Committee recognises the continuing public frustration regarding rescheduled
outpatient appointments and the negative impact these have on patient experience
and the quality of care. This is a major area of concern articulated by patients and
the public to the Committee over the last year.
Page 81 of 93
Quality Account 2012-13
Dignity must be centre stage in a care system which is underpinned by respect,
compassion and sensitivity – not only from organisations who are commissioned to
provide care but crucially from the individuals who work within them. The Committee
supports the strong emphasis by the Trust on ‘caring’ as outlined in the ‘Making it
Better Together’ programme. However, anecdotal evidence to the Committee is
mixed with patients reporting both exemplary practice but also some examples of
poor care.
The Committee supports the goal of a value driven organisation to improve safety,
patient experience and quality of services and recognises the value of leadership
that is shared, distributed and adaptive. It is important that leaders focus on systems
of care and on engaging staff from all backgrounds who have a responsibility to
ensure the core purpose of the Trust- to delivering high-quality patient care and
outcomes – is at the heart of what they do.
Anecdotal evidence suggests that in a minority of cases this does not always happen
within the Trust and that patient experience is influenced by service and location.
Patients tell us that the quality of their experience differs from service to service and
between locations. The ethos of having ‘one service’, i.e. one set of care pathways,
and one culture so that where ever the patient enters the services, they access the
same high level of high standards of care is clearly important. This ‘ethos’ must run
through the entire organisation and apply to all services across all three hospital
sites if the performance of the Trust is to consistently match the best performers in
the NHS.
The Committee notes the reference in the Quality Account to fewer staff feeling
satisfied with the quality of their work than in previous years. It is clear that the
significant challenges facing the Trust over the next year will impact on staff. It is vital
that the Trust manage people well and treat all staff with dignity and respect.
Motivated staff will lead to improved patient experience and better quality outcomes.
The Committee welcomes the improved performance in relation to reducing pressure
ulcers – their prevention is a fundamental part of ensuring high quality patient care,
promoting patient safety and health service efficiency.
The focus on patient safety will be a key element of the Committee’s work
programme over the next 12 months. The quality priority to increase incident
reporting rates to that of the top 25% of Trusts was recommended for inclusion by
the Committee. The objective must be to reduce patient safety incidents by
increased reporting by building a safety culture that is open and fair, and to foster an
environment where the whole organisation learn from safety incidents and where
staff are encouraged to report and proactively assess risks.
The Committee believes that the Quality Account represents a statement of intent by
the Trust the core purpose of which is the delivery of high-quality patient care and
outcomes. Successful implementation will require sustained leadership and
leadership succession that maintains a focus on improving performance. The
Committee is grateful for the opportunity to comment on the Quality Account and
Page 82 of 93
Quality Account 2012-13
looks forward to supporting and working with the Trust in reviewing performance
against the quality indicators over the coming year.
Page 83 of 93
Quality Account 2012-13
Quality Account 2012/2013
Mid Yorkshire Hospitals NHS Trust comments by Healthwatch Wakefield
Healthwatch Wakefield thanks the Mid Yorkshire NHS Trust (The Trust) for the
opportunity to comment on the Trust’s Quality Account for the year 2012/2013.
This commentary is prepared with the help of the legacy left by our predecessor
Wakefield Local Involvement Network (LINk) and also from the information gathered
from attendance until March 2013 at the quality and clinical governance meetings of
the Trust, which was most useful.
The LINks left the following legacy and areas to monitor in relation to MYH NHS
Trust.
1. Revalidation of registration of doctors by the general medical council, which
started in December 2012.
2. Handover of acute care from one doctor to another, from one speciality to
another and from one hospital to another.
3. Liaison nurse for dementia patients
4. Clinical negligence scheme for the Trust (CNST) payments made by the NHS
litigation authority on behalf of the Trust and the CNST level payments made
by the Trust.
To prepare the comments we made a Task Group of 8 members but most of them
were unable to attend the meetings because of the short notice. But two members
who did attend made a very useful contribution. One of the members is a volunteer
at the Alzheimer’s Society and helps two patients with this disability.
Finally we had a meeting with the Trust representatives consisting of the following:
1. Assistant Chief Nurse
2. Medical Director of the Trust
3. Director of Communications and Engagement
In the meeting held 22nd May 2013 it was confirmed that the Quality Accounts are in
accordance with the requirements of NHS Act 2009 and 2012 (in the draft accounts
two or three items are missing but the final version of the accounts will contain that
information)
In the same meeting following items were discussed.
Page 84 of 93
Quality Account 2012-13
1. Progress report on the priorities in the last quality accounts
2. Your organisations current standardised mortality ratios (we will get Dr Foster
data from their website)
3. Patient safety incidents – reporting and learning as publicised by the old
NPSA and recently by the new commissioning board.
4. Your current CNST (Clinical Negligence Scheme for Trusts) payment level –
We will get information about your last year payments from the website of
NHS litigation authority
5. Annual staff appraisals - Percentage of staff appraised so far this year
6. Progress on five yearly re-validation on medical staff
7. Nurse patient ratio, and the ratio of trained nursing staff and health assistants
8. Hospital inquired Infections
9. Incidents of bed sores
10. Number of falls
11. Medication errors
12. Progress report on productive wards
Patient experience
1. Any surveys of patient satisfaction rates conducted by the Trust
2. Any national surveys on patient satisfaction survey rates
3. Patient outcome surveys
General Topics
1. Francis report and are there any lessons to be learnt from the Trust
2. Being open and Duty of Candour
3. Care Quality Commission’s reports on your Trust and any pending action
required.
4. Patient & Public Involvement policies of the Trust
5. Non-Executive Directors – Are there any non-executive directors with
responsibility on patient safety and on being open
6. How can staff members express concerns (Whistleblowing)
7. Policies regarding hand over of clinical care between specialty, department
and clinical teams.
Based on the information gathered and to the best of our knowledge the Quality
Accounts are a correct and honest record.
We would like to make the following comments:
1. The Trust has continued to provide reasonable quality of services in spite of
the impending services reconfiguration and uncertainties which are impairing
staff moral as is clear from staff survey from 2011/2012. Which showed that
the Trust remains in the worst 20% of acute Trusts in the following
categories:
Page 85 of 93
Quality Account 2012-13
•
•
•
•
Staff recommendation of the Trust as a place to work or receive
treatment
Staff motivation at work
Staff reporting patient safety incidents
Staff have well-structured appraisals
2. We congratulate the Trust for being amongst the best performer nationally in
Care Quality Commission survey in the following categories:
• For not changing admission dates by the hospital
• Providing enough help from staff to patients for eating meals
3. However in the same survey the Trust did not perform well in the perception
of enough nurses being on duty and on providing clear information on
medicines.
4. We congratulate the Trust for achieving three out of five priorities for
improvement for 2012/2013 and they have made significant gains in the other
two priorities.
5. Trust took part in significant number of audits nationally and locally and we
note the changes in the clinical practices introduced as a result of local audits.
6. The Trust has made a significant improvement in the diagnosis and care of
patients with dementia and we applaud that.
We wish the Trust good luck in the priorities 2013/2014 especially priority number
four in which they have not performed well since the very beginning.
The Task Group regards Quality Accounts as a continuous process of improvement
and with this in mind the Task Group will remain active throughout the year and
would like to meet the Trust on a three monthly basis.
N K Mathur, LINk lead for Quality Accounts and on behalf of
Healthwatch Wakefield
Page 86 of 93
Quality Account 2012-13
NHS Wakefield Clinical Commissioning Group
MYHT Quality Account 2012/13
Commissioning CCG Written Statement
The following statement is presented on behalf of the commissioning partners of Wakefield
and North Kirklees Clinical Commissioning Groups.
We welcome the opportunity to comment on the Trust’s Quality Account for 2012/13. The
account is an open and comprehensive assessment of the quality of patient care provided
over the year. The content reflects our discussions with the Trust about the quality of care
at our Executive Quality Board meetings (which form part of our regular contract
monitoring).
High levels of demand for services and continued financial pressures pose a challenge for
the Trust. There has also been cause for some concerns following recent CQC inspections at
Dewsbury which resulted in minor compliance actions. We have noted the continued rise in
patient complaints and the number of complaints subsequently referred to the
Ombudsman.
The Trust has been open about these challenges and works closely with Commissioners in
areas of concern. This strengthened relationship was evident in a series of constructive
health summits involving key partners across the health economy. We are assured that the
Trust is committed to undertaking significant and ambitious programmes of review and
improvement and look forward to seeing the impact of these improvement programmes
over the coming year.
We are pleased that the Trust has achieved a number of their quality priorities. Mortality
rates have improved and are now in line with national averages. The Trust has also
implemented the national NHS Safety Thermometer which provides valuable information on
key markers of patient safety and has evidenced good performance in Venous
Thromboembolism Assessment (VTE). The Trust has also undertaken significant work in
both acute and community services to improve the screening and management of patients
with dementia. We keenly anticipate seeing the benefits of this work in the coming year,
which will be monitored as part of national CQUIN indicators. Importantly, there have also
been no Mixed Sex Accommodation Breaches since July 2012 and zero Never Events over
the year.
Despite ongoing commitment, the Trust did not meet their priorities for MRSA. This does
not reflect the significant progress the Trust has made in the infection control agenda,
evident in the reduced number of cases of Clostridium Difficile reported. We are also
disappointed with the progress made in improving patient experience of Outpatients. We
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Quality Account 2012-13
are pleased that the Trust has identified this as part of their continuing organisational
improvement priorities, alongside a focus on complaints management and lessons learned.
We applaud the Trust’s candour in acknowledging the findings of the national NHS Staff
Survey and NHS Inpatient Survey, both valuable pieces of work which tell us how staff and
patient experience working and receiving care at the Trust. The Trust is actively undertaking
work to improve these areas and we will continue to monitor their progress over the year.
We support the Trust’s choice of quality priorities for 2013 / 14. Improvements in these
areas will have major benefits for a large number of patients. However, as an organisation
with a key objective to integrate hospital and community services, we are disappointed that
the account has not been more explicit in their achievements in community services over
the year and whether new priorities include, where relevant, these services.
The Trust is actively seeking to match the best performance in the NHS. The Quality
Account demonstrates a clear understanding that quality is based on developing an
organisational culture which values individual staff and the organisation as a whole. The
Trust is continuing to work to develop this culture through promoting organisational core
values of caring, respect, high standards and improvement.
As commissioners, we will continue to work collaboratively with the Trust to improve the
quality of services for the local community. We will provide challenge and support where
required and look forward to seeing the impact on these ambitious programmes of
improvement throughout 2013/14.
Wakefield Clinical Commissioning Group
North Kirklees Clinical Commissioning Group
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Quality Account 2012-13
INDEPENDENT AUDITORS’ LIMITED ASSURANCE REPORT TO THE DIRECTORS OF THE MID
YORKSHIRE HOSPITALS NHS TRUST ON THE ANNUAL QUALITY ACCOUNT
We are required by the Audit Commission to perform an independent limited assurance
engagement in respect of The Mid Yorkshire Hospitals NHS Trust’s Quality Account for the year
ended 31 March 2013 (“the Quality Account”) and certain performance indicators contained therein
as part of our work under section 5(1)(e) of the Audit Commission Act 1998 (the Act). NHS trusts are
required by section 8 of the Health Act 2009 to publish a Quality Account which must include
prescribed information set out in The National Health Service (Quality Account) Regulations 2010,
the National Health Service (Quality Account) Amendment Regulations 2011 and the National Health
Service (Quality Account) Amendment Regulations 2012 (“the Regulations”).
Scope and subject matter
The indicators for the year ended 31 March 2013 subject to limited assurance consist of the
following indicators:
•
Percentage of patient safety incidents that resulted in severe harm or death; and
•
Percentage of patients risk-assessed for venous thromboembolism (VTE).
We refer to these two indicators collectively as “the indicators”.
Respective responsibilities of Directors and auditors
The Directors are required under the Health Act 2009 to prepare a Quality Account for each financial
year. The Department of Health has issued guidance on the form and content of annual Quality
Accounts (which incorporates the legal requirements in the Health Act 2009 and the Regulations).
In preparing the Quality Account, the Directors are required to take steps to satisfy themselves that:
• the Quality Account presents a balanced picture of the trust’s performance over the period
covered;
• the performance information reported in the Quality Account is reliable and accurate;
• there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to review to
confirm that they are working effectively in practice;
• the data underpinning the measures of performance reported in the Quality Account is robust
and reliable, conforms to specified data quality standards and prescribed definitions, and is
subject to appropriate scrutiny and review; and
• the Quality Account has been prepared in accordance with Department of Health guidance.
The Directors are required to confirm compliance with these requirements in a statement of
directors’ responsibilities within the Quality Account.
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 Account is not prepared in all material respects in line with the criteria set out in the
Regulations;
•
the Quality Account is not consistent in all material respects with the sources specified in the
NHS Quality Accounts Auditor Guidance 2012-13 issued by the Audit Commission on 25 March
2013 (“the Guidance”); and
•
the indicators in the Quality Account identified as having been the subject of limited assurance
in the Quality Account are not reasonably stated in all material respects in accordance with the
Regulations and the six dimensions of data quality set out in the Guidance.
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Quality Account 2012-13
We read the Quality Account and conclude whether it is consistent with the requirements of the
Regulations and to consider the implications for our report if we become aware of any material
omissions.
We read the other information contained in the Quality Account and consider whether it is
materially inconsistent with:
•
Board minutes for the period April 2012 to June 2013;
•
papers relating to the Quality Account reported to the Board over the period April 2012 to June
2013;
•
feedback from the Commissioners dated June 2013;
•
feedback from Local Healthwatch dated June 2013;
•
feedback from other named stakeholder(s) involved in the sign off of the Quality Account;
•
the latest national inpatient survey 2012, published February 2013;
•
the latest national staff survey 2012;
•
the Head of Internal Audit’s annual opinion over the trust’s control environment dated
03/05/2013;
•
the annual governance statement dated 24/05/2013;
•
Care Quality Commission quality and risk profiles.
We consider the implications for our report if we become aware of any apparent misstatements or
material inconsistencies with these documents (collectively “the documents”). Our responsibilities
do not extend to any other information.
This report, including the conclusion, is made solely to the Board of Directors of The Mid Yorkshire
Hospitals NHS Trust in accordance with Part II of the Audit Commission Act 1998 and for no other
purpose, as set out in paragraph 45 of the Statement of Responsibilities of Auditors and Audited
Bodies published by the Audit Commission in March 2010. We permit the disclosure of this report to
enable the Board of Directors to demonstrate that they have discharged their governance
responsibilities by commissioning an independent assurance report in connection with the
indicators. To the fullest extent permissible by law, we do not accept or assume responsibility to
anyone other than the Board of Directors as a body and The Mid Yorkshire Hospitals NHS 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 under the terms of the Audit Commission Act
1998 and in accordance with the Guidance. 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;
•
testing key management controls;
•
analytical procedures;
•
limited testing, on a selective basis, of the data used to calculate the indicators back to
supporting documentation;
•
comparing the content of the Quality Account to the requirements of the Regulations; and
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Quality Account 2012-13
•
reading the documents.
A limited assurance engagement is narrower in scope than a reasonable assurance engagement. The
nature, timing and extent of procedures for gathering sufficient appropriate evidence are
deliberately limited relative to a reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial
information, given the characteristics of the subject matter and the methods used for determining
such information.
The absence of a significant body of established practice on which to draw allows for the selection of
different but acceptable measurement techniques which can result in materially different
measurements and can impact comparability. The precision of different measurement techniques
may also vary. Furthermore, the nature and methods used to determine such information, as well
as the measurement criteria and the precision thereof, may change over time. It is important to read
the Quality Account in the context of the criteria set out in the Regulations.
The nature, form and content required of Quality Accounts are determined by the Department of
Health. This may result in the omission of information relevant to other users, for example for the
purpose of comparing the results of different NHS organisations.
In addition, the scope of our assurance work has not included governance over quality or nonmandated indicators which have been determined locally by The Mid Yorkshire Hospitals NHS 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 Account is not prepared in all material respects in line with the criteria set out in the
Regulations;
•
the Quality Account is not consistent in all material respects with the sources specified in the
Guidance; and
•
the indicators in the Quality Account subject to limited assurance have not been reasonably
stated in all material respects in accordance with the Regulations and the six dimensions of data
quality set out in the Guidance.
Paul Dossett
Senior Statutory Auditor, for and on behalf of Grant Thornton UK LLP
No.1 Whitehall Riverside
Leeds
LS1 4BN
28 June 2013
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Quality Account 2012-13
Glossary of Terms
Care Quality Commission
The independent regulator of health and social care
Clostridium Difficile
Bacteria that are present naturally in the gut of 2/3rds of
children and 3% of adults. It does not cause problems in
health adults however, antibiotics can upset the balance
of good bacteria and when this happens bacteria
(poisons) can be produced
CQUINN
Commissioning for quality and innovation
Dementia
A general term for a decline in mental ability severe
enough to interfere with daily life
Executive Quality Board
A meeting of executive leaders from Wakefield and
Kirklees Clinical commissioning groups. The meeting
reviews the quality of service and holds Trust colleagues
to account for delivery of agreed plans
Hospital Acquired Infection
Infection in which the patient acquires in hospital
Hospital Standardised Mortality Rate
(HSMR)
An indicator of healthcare quality that uses a statistical
number to compare mortality (death) rates between
hospitals
Joint Consultative Negotiating
Committee
Local Involvement Network
A meeting of management with the recognized unions
Mixed Gender Breach
When both genders share sleeping accommodation
Morbidity Rates
Incidence of disease
Mortality Rates
Rates of death
MRSA Bacteraemia
Blood stream infection caused by MRSA
National Reporting and Learning
System
A database of patient safety information to identify and
tackle important patient and safety issues at their root
cause
Never Event
Events which should never happen in health care
organizations if safe processes are in place
Non Executive Directors
NCAPOP
Members of the board who do not form part of the
executive team
National clinical audit and patient outcome programme
Overview and Scrutiny Committee
A function of local authorities led by councilors to
A network of local groups to give communities a stronger
voice in health and social care (Replaced by Health
watch)
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Quality Account 2012-13
(OSC)
consider, review and analyse decisions taken by public
bodies such as health
Patient Safety Panel
A weekly meeting of staff, clinical and managerial who
discuss reported incidents. These are reviewed and
learning identified so that action can be taken. Patient
Safety learning is then cascaded via a bulletin to all Trust
staff
Pressure ulcer
Damage to tissues caused by pressure (previously called
bed sores)
PROMS
Patient reported outcome measures
Quality and Clinical Governance
Committee
A sub committee of the Trust Board established to
provide scrutiny and assurance to quality of service
Registered Activities
Activities (or services) carried out by the Trust which are
regulated by the Care Quality Commission, e.g. X rays
Registered locations
Sites from which the Trust is licensed to provide care
Safety Thermometer
A snap shot study undertaken monthly which focuses on
the provision of harm free care
NHS Trust Development Authority
Provides governance and accountability for NHS Trust
and delivery of Foundation Trust pipeline. It helps NHS
Trusts secure sustainable high quality services for
patients and the communities they serve
VTE
Venous Thromboembolism (a clot in the blood vessels)
West Yorkshire Comprehensive
Research Network
A network of organizations involved in health research
across West Yorkshire
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