Building for Excellence
Quality Accounts 2012/13
Building for Excellence
1
The Princess Alexandra Hospital NHS Trust
Published May 2012 - www.pah.nhs.uk
Building for Excellence
CASE STUDY
Achieving Excellence in Patient Experience through Patient
Centred Services
2012 saw of an important shift in how we work with you, our patients, at The
Princess Alexandra Hospital NHS Trust.
The launch of the Patient Experience Team in October 2012 brought a fresh focus to
the way we engage with patients, their families and other carers. We changed our
approach to communicating with users of our services, so that we improved how we
learned from past experiences, ensuring that the Trust’s progress is guided by the
public.
Our objective was to create a more open and transparent culture where we work
closely with the local population. A number of initiatives were launched which are
already having positive benefits:
Weekly ‘one-stop-shops’ which now operate at each of our hospital sites provide
patients, carers and visitors with the opportunity to give feedback about their recent
care, and to discuss any on-going concerns face-to-face with a member of staff.
In November 2012 we launched ‘Both Sides Now’. Through film, staff and patient
stories have been presented to the Board, which is responsible for ensuring that we
make the changes to improve the patient experience.
Of course, our ultimate goal is to move towards a position where all concerns or
questions are dealt with immediately, meaning that a resolution is reached at the
point of care and not after the patient has returned home. We are encouraging
patients to ask more questions and involve themselves in their care, ensuring no
decision is made without their input.
As a result of this work the number of complaints has decreased, while the number
of compliments has improved dramatically.
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
CASE STUDY
Achieving Excellence in Infection Prevention and Control
•
The Princess Alexandra Hospital NHS Trust is in the top seven of all (159) NHS
Trusts in England for Clostridium difficile control
•
Only two acute trusts in England have a lower C. diff rate than PAHT, and
one other has the same rate as the Trust
•
This is a remarkable achievement considering the operational constraints faced
by the Trust
•
We made significant improvements, but our target becomes more challenging as
we achieve more and is only 9 cases for 2013/14, one of the tightest in England
•
Next year our target is only 2 cases more than Great Ormond Street and
Papworth, despite being a district general hospital with a significant elderly
population and unselected admissions
•
This year we plan to introduce hydrogen peroxide decontamination of side rooms
in addition to the usual control measures of: antibiotic control, good hand
hygiene, rapid isolation, personal protective equipment & cleaning with chlorine
based product
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
Contents
Page 5
Statement from the Chief Executive
Page 7
Statement of Directors’ Responsibilities in Respect of the Quality
Accounts
Page 8
Performance against priorities from 2012/13
Page 21
Other priorities from 2012/13
Page 24
Priorities for Quality Improvement in 2013/14
Page 27
Statements relating to quality of NHS Services provided
Page 27
A Review of Services
Page 28
Participation in clinical audit and research
Page 41
Care Quality Commission
Page 43
Use of CQUIN Payment Framework
Page 44
Stroke Service
Page 45
Never Event
Page 45
Statement on Relevance of Data Quality
Page 45
Data quality metrics and processes
Page 48
Review of Quality Performance
Page 48
How the Trust identifies local improvement priorities
Page 48
Areas of improvement and development across the Trust
Page 49
Development of the Trust’s Clinical Service Strategy - A Year of the
Clinically-led team
Page 49
Report on Complaints
Page 53
Performance against key national priorities 2012/13
Page 56
Performance against local quality indicators in 2012/13
Page 58
Summary of indicators NHS Outcomes Framework domain
Page 60
External Audit Opinion
Page 64
Statements from our Stakeholders and Commissioners regarding the
final report.
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
Statement on Quality from the Chief Executive
2012/13 was significant in terms of quality for all providers of NHS care as we
anticipate the publication of Francis Report in March 2013 and the system failures it
described at Mid Staffordshire Hospital. At The Princess Alexandra Hospital NHS
trust (PAHT) the top priority remains patient safety as demonstrated by our first
strategic goal: Excellent safety and outcomes for patients. As a Board we have
undertaken an initial review of the Francis recommendations to assess how we will
implement them and further improve patient safety and quality.
There were many achievements in quality, safety and the patient experience
throughout the Trust in 2012-13. The Trust achieved the 95% four hour wait
standard in Accident and Emergency (over 95% of our patients were seen, treated
and discharged from A&E within four hours), achieved the 90% 18 week referral to
treatment standard (over 90% of our patients received their initial treatment within 18
weeks of a GP referral) and underwent a successful external assessment of its
maternity services, retaining Level 2 of the Clinical Negligence Scheme for Trusts.
We appointed some key staff including: a new Director of Nursing and Quality, Chief
Operating Officer, Head of Patient Safety and Quality, and Head of Patient
Engagement. These new colleagues have extended our ability to improve patient
safety. Our Board committee structure was also reviewed and updated to ensure
that we consider the quality of our services alongside their performance against local
and national standards.
This year has also seen a step change in our drive to improve the patient
experience. Our improvement is demonstrated by the reduction in the number of
complaints we have received and the high numbers of compliments that we have
received. As part of the Achieving Excellence programme, the Trust launched
several programmes of work that will help to transform the patient experience,
including In Yours Shoes workshops for patients and staff, and the establishment of
a patient panel.
Whilst the Trust failed its threshold for the number of cases of MRSA and Clostridium
difficile, it remains one of the top performing organisations in England for preventing
Health Care Acquired Infections and is in the top seven of all NHS Trusts in England
for C. diff control. This is due to the dedication of our staff, and in particular the
Infection Control Team.
The Trust’s Hospital Standardised Mortality Ratio (HMSR) has shown improvement
during the year and we expect this to continue. The Summary Hospital-Level
Mortality Indicator (SHMI) rate remains within the expected range. Both of these are
health quality measures of the mortality rate within hospitals.
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
Notwithstanding areas of good performance in 2012/13, there were also some
disappointments. The work to address the performance against the cancer standards
has not delivered to the extent we would have liked and the Trust did not perform as
well as it had hoped in the inpatient and staff surveys. There was a significant
improvement in the number of patients being risk assessed for Venous
Thromboembolism in the latter part of the year, but we fell short of the 95% target
overall.
In January 2013 the Strategic Health Authority (SHA) called a Risk Summit to
discuss concerns raised about the Trust by our commissioners in West Essex. We
took a collaborative approach to addressing their concerns to provide assurance to
our wider stakeholders in the health economy that we:
had created a clinically led organisation in order to deliver our vision and
improvements;
are committed to promoting a culture of openness and transparency;
had made significant improvements in a range of areas such as improved
mortality, reduction in hospital acquired avoidable pressure ulcers, and
demonstrable learning from incidents;
are aware of the areas that require improvement and are addressing them;
have revised our governance, systems and processes to support improvement
and delivery;
will continue to work with our partners to ensure high quality services for patients.
The outcome of the summit was an acknowledgement that the Trust had already
dealt with a number of the historic issues that had been raised and that the SHA
were confident that we were well placed to deliver on the action plans that were
already in place. It was clear that the one of the main challenges was financial
investment across the health economy to ensure sustained quality improvements.
2012/13 has been a good year for improving quality within the Trust and I am
confident that the hard work of our team and our stakeholders has had a positive
impact on our patients. We are in a strong position to sustain our quality
improvements in the year ahead. This is covered in more detail throughout the
Quality Accounts, which the Board and I are pleased to be able to present to you.
Melanie Walker
Chief Executive Officer
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
Statement of Directors’ Responsibilities in Respect
of the Quality Accounts
The directors are required under the Health Act 2009, National Health Service
(Quality Accounts) Regulations 2010 and National Health Service (Quality Account)
Amendment Regulation 2011 to prepare Quality Accounts for each financial year.
The Department of Health has issued guidance on the form and content of annual
Quality Accounts (which incorporate the above legal requirements).
In preparing the Quality Accounts, directors are required to take steps to satisfy
themselves that:
The Quality Accounts presents a balanced picture of the Trust’s performance
over the period covered;
The performance information reported in the Quality Accounts 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
Accounts are robust and reliable, conform to specified data quality standards and
prescribed definitions, is subject to appropriate scrutiny and review. The Quality
Accounts have been prepared in accordance with Department of Health
guidance.
The directors confirm that, to the best of their knowledge and belief, they have
complied with the above requirements in preparing the Quality Accounts.
By order of the Board
Douglas Smallwood
Chairman
Melanie Walker
Chief Executive Officer
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
Performance against priorities - 2012/13
In last year’s Quality Accounts, the Trust detailed a number of quality priorities it was
to focus on throughout the year.
1)
Patient Safety: Detecting the deteriorating patients
o
Implement the Patient Safety First five key interventions for reducing
harm from deterioration
o
Ensure that we achieve the national target of 95% of patients or more
who have a risk assessment for venous thromboembolism (VTE)
What we did in 2012/13
The Trust continues to work with the Patient Safety First campaign to
eliminate avoidable harm and avoidable death in hospital. The campaign
covers five areas and this Quality Account reports on our work over some
of these elements, including:
o Leadership for safety
o Reducing harm from deterioration
o Reducing harm in critical care
o Reducing harm in perioperative care
o Reducing harm from high-risk medicines
The Trust consistently achieved the target for ensuring 95% or more of
patients had a risk assessment for VTE between November 2012 and the
end of March 2013. Prior to this the Trust’s performance had been
variable, between 90% and 94%. The Trust did not achieve the annual
target, achieving 93.63%, nevertheless performance has significantly
improved and we did this by implementing clinical champions in key areas,
such as the emergency department, who promoted the use of the
assessment tool and ensured that their colleagues were compliant. A
Clinical Director was appointed as overall lead for the target to ensure that
the profile of deep vein thrombosis and pulmonary embolism was raised.
What we plan to do in the next 12 months
The Trust will sustain and improve its performance against the VTE target,
continuing with clinical leadership. The Trust has agreed with its
Commissioners a target of 98% of patients undergoing a risk assessment
for VTE and will work towards this in incremental stages in 2013/14.
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Building for Excellence
2)
Patient Safety: Medication errors or omissions
o
Improve anticoagulation prescribing
o Introduce standardisation of Total Parenteral Nutrition (TPN) for
neonates (new born babies) as part of an East of England regional
network plan
What we did in 2012/13
The Trust’s anti-coagulant drug chart was updated and improved to
include the use of a new treatment option and the management of anticoagulants during the perioperative period. The pathway for anticoagulant patients who do not attend their blood tests has also been
improved to identify those patients early and send additional reminders.
The Trust successfully introduced the standardisation of TPN for neonates
and follows the East of England regional network plan. The Trust
submitted the required returns during 2012/13.
What we plan to do in the next 12 months
The Trust will continue to monitor anti-coagulant prescribing as part of its
clinical pharmacy service at ward level to ensure patient safety.
3)
Patient Safety Thermometer
o
Reducing harm by audit, using the NHS Safety Thermometer to
measure outcomes for VTE, pressure ulcers, falls and urinary tract
infections in patients with catheters, and implement appropriate actions
What we did in 2012/13
The Trust introduced the Patient Safety Thermometer to measure the
delivery of harm free care to patients. We have sustained a monthly audit
in line with the national requirements.
PAHT introduced an Essence of Care Scrutiny Panel chaired by the
Deputy Director of Nursing to review, with clinical teams, the reports for all
falls and pressure ulcers and ensuring that the learning from each incident
is shared across all directorates.
What we plan to do in the next 12 months
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
The Trust is concentrating on two elements of the Patient Safety
Thermometer in 2013/14, pressure ulcers and falls. The Trust plans to
reduce the prevalence of avoidable incidents of both pressure ulcers and
falls.
The Trust has refreshed and rebranded the pressure ulcer ambition to
remove avoidable grade 3 and 4 pressure ulcers and will achieve this
through strong clinical leadership from the Matrons and Senior Sisters. In
addition the Trust has launched Agents for Nutrition and Tissues Viability
(ANTs) for each Ward, which are staff specially trained in this area.
The Falls Group and the Falls Ambition have been reviewed and their
areas of work reprioritised, with a new medical chair of the Falls
Committee. The Director of Nursing and Quality is now the executive
champion of falls. Formal training on falls causation and prevention will be
delivered at induction, in preceptorship courses and on clinical update
sessions. Training will also be commencing for junior doctors on their
commencement with the Trust. The Trust has also reviewed the falls risk
assessment tool following feedback from clinical Fridays where areas for
improvement in practice were identified.
PAHT has invested falls
prevention with new ultra low beds and is procuring bed and chair sensors
with alarms.
4)
Patient Safety: Safeguarding the vulnerable
o Implement dementia risk assessment for all patients admitted over the
age of 75 years
o Streamline and implement effective discharge planning
o Embed the learning disability and autism quality assurance framework
What we did in 2012/13
The Dementia Screening question was incorporated into the Emergency
Assessment Proforma for all patients 65 years and above midway through
the year, and this was monitored for compliance. The Trust achieved
monthly improvements. A flow chart was developed and shared with
clinicians to identify the process for dementia screening through to further
assessment and identification for referral to memory clinic on discharge.
In 2012 the Trust implemented the use of the QFI Discharge Jonah
system, an electronic discharge prediction tool. This assisted the
introduction of a regularly updated priority list to reduce the incidence of
non-clinical disruption or delay to patients’ journeys through the hospital.
The system was chosen as it recognises that it is far better to identify and
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
eradicate the cause of delays, than to accept that delays will occur and
build them into the expected patient journey.
Transforming the discharge process to ensure that patients receive
individualised patient care, through the use of effective multi-disciplinary
working, is key to ensuring that delays are recognised, recorded and
eradicated. The implementation of the Jonah discharge planning system
underpinned this process. The system enables the Trust to achieve clinical
effectiveness by ensuring that we are ‘doing the right thing in the right way
for the right patient at the right time.’1
On admission the multi-disciplinary teams sets the patient’s predicted date
of discharge (PDD). Daily patient journey meetings are held on each ward
to facilitate early discharge planning, and to expedite early referral to any
of the health or social care agencies required to support the patient’s
discharge from hospital. The Trust has worked to ensure effective multiagency working by ensuring that colleagues from social care are also able
to access the Jonah system to allow them to progress patients’ social care
needs. Ward based staff and the discharge team then monitor the
progress of patients requiring social care input allowing a joined up
approach to patient care.
Top delay meetings are held twice weekly at which the top 25 delayed
patients are discussed and case managed. Attendees from the hospital
along with representatives from the wider health and social care economy
come together to ensure a system wide approach to tackling any delays
identified in the system. By providing a forum for challenge and escalation,
actions can be allocated appropriately to ensure that patients’ on-going
care needs are met in the most appropriate environment within agreed
timescales.
Where delays (which are not attributed to the patient’s medical condition)
do occur, these are logged on the system to allow the Trust to examine the
reasons and to target the specific root cause of delays. It is only through
the identification of the root cause of the delay that we are able to best
improve the patients’ experience and reduce their length of stay.
As part of the work to improve patients’ experience and to reduce length of
stay, an exciting redesign of the Discharge Lounge was undertaken. This
work created a more welcoming and friendly environment for those
patients awaiting transport home following their discharge from wards. The
redesign has meant the introduction of more comfortable seating, along
with the ability for patients requiring transport on a stretcher to be safely
1
Royal College of Nursing (1996) What is clinical effectiveness. London: RCN p.3.
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Building for Excellence
accommodated within the Discharge Lounge. The increased space and
ability to accept a wider range of patients has meant that the Discharge
Lounge is used to its full potential, meaning we are able to reduce the
need for patients to remain in beds while they wait to leave the hospital
and return to their homes.
During 2012/13 we made excellent progress in meeting the needs of
patients with learning disabilities (LD) and autism who are admitted to
hospital. Our work included:
o Establishing a Learning Disabilities Steering Board chaired by a
Non-Executive Director and including carer, service user and
external stakeholder representation
o Launching LD and Autism Awareness sessions for all patient facing
staff. 470 staff have been trained so far
o Establishing a network of senior clinical champions/link practitioners
in each of the clinical directorates
o Setting up alerts in our patient administration system and incident
recording system to proactively identify patients with LD and autism
o Production of outpatient letters in Easy Read format for patients
with LD and autism
o Amending our discharge policy to make specific reference to, and
include specific questions relating to, patients with LD and autism
o Appointing a full time LD Liaison Nurse
o Appointing a LD service user as a volunteer with the Patient
Experience Team
What we plan to do in the next 12 months
For patients identified with dementia, further adaptations to discharge
summaries are planned to include capture of referral to memory clinics and
confirmation that relatives and carers have been included in discussions
about discharge. The Trust is working in collaboration with its
Commissioners to manage the concerns raised regarding gaps in the
availability of memory clinics and patient and carer expectations.
The Trust will be working with its Commissioners to improve the quality of
the discharge planning process and patient experience, ensuring that
patients and carers receive the information they need when leaving the
hospital. This work will be delivered by a multidisciplinary working group.
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Building for Excellence
The Trust will continue its programme of work to support patients with LD
and autism, including increasing the production of patient information in
the Easy Read format, and ensuring that all patient facing staff undergo
the awareness training.
6)
Patient Engagement and Experience:
o To focus on improvements in patient communication and discharge
What we did in 2012/13
Looking back
2012/13 saw the beginnings of an important shift in how we work with you, our
patients at The Princess Alexandra Hospital NHS Trust.
The need to deliver the highest quality patient centred, clinically led care was
emphatically underlined. Most of all, by the findings of The Mid Staffordshire
NHS Foundation Trust Public Inquiry chaired by Sir Robert Francis QC, but
equally by the rapid changes in the way you, our patients and your supporters,
engage with the us in the NHS.
The NHS is open to public and individual scrutiny in many ways, through
systems established for some time, but some of these are only now bearing
real fruit. Patients are able to use Google Local, NHS Choices, Patient
Opinion, Patient Experience Blogs, The Princess Alexandra Hospital NHS
Trust Facebook page, a Twitter account, comment
cards, the PALS team and innumerable other Responding
systems to make a compliment or comment, or even You Said
write a letter to the Chief Executive.
What you, the public want
However, whilst fewer of you than ever are choosing
to write a letter to the Trust, many of you are making
your views known through other methods.
At the last count The Princess Alexandra Hospital
NHS Trust had:
1850 likes on our Facebook page
650 twitter followers
53 NHS Choices comments
Some of the effects of these changes can already be
seen in:
The Princess Alexandra Hospital NHS Trust
“members of the public should
not have to pay to make a
complaint, it should be free to
complain or make a comment”
Telephone call to Patient
Experience Team
We Did
The Princess Alexandra Hospital
NHS Trust now has a freepost
address and you can now write
to us with your comments
concerns and compliments at no
cost to you (The Patient
Experience Team, FREEPOST
RTCS-ZHRB-RSGL, Hamstel Road,
13
Harlow, Essex CM20 1QX).
Building for Excellence
the 42% reduction in the number of complaints year on year - 466 in
2012/13 compared to 665 in 2011/12
the increasingly local resolution of concerns – 2300 PALS cases in
12/13
the rapid increases in the number of recorded positive compliments,
specifically a six-fold increase month on month in the last months of
2012/13 to 199 in January 2013 from 36 in November 2012.
Much of this work had already begun in early 2012 when the hard work of the
previous Patient Experience Team began to have an effect, as is shown in the
information graphics in the report on complaints later in these Quality
Accounts.
What we plan to do in the next 12 months
Looking forward: Listening, Responding and Improving
The Princess Alexandra Hospital NHS Trust is planning a significant
expansion in the way we gather your views and translate those into a real
difference at the point of care.
The new Patient Experience Team has identified about three steps in every
experience which leads to a change; those are Listening, Responding and
Improving, and you can read our short eight page information leaflet anywhere
in the hospital or online to find out more about what that means.
Some of the ways we have already begun this process of opening up the
organisation to your input are as follows:
1. In Your Shoes – patient experience listening events for continuous
improvement. You can ask to participate if you want to tell your story and join
former patients we’ve invited to participate. We will use this forum to identify
and address the concerns patients expressed in the patient survey such as
confidence/ trust in doctors and the need to improve explanations of the risks/
benefits of an operation/procedure and what would happen during the
operation.
2. Both Sides Now – staff and patients tell their stories together about what
needs to change and then we present those stories to our Board who are then
accountable for ensuring that the organisation makes the changes patients
have asked for
3. The One Stop Shop – a mobile PALS clinic which goes to you wherever
you are, in the coffee shop, at your Outpatient appointment or in the
Boardroom. You choose and it is our role to help resolve challenges around
your care there and then
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Building for Excellence
4. Resolution at the Point of Care – ward level leadership to make the patient
experience the best it can be has been championed by our Heads of Nursing
who are real champions of excellent patient experience.
5. Improving Access
Freepost address so you can write to us at no cost to you, or answer
letters we send you without needing a stamp
Comment card/just a minute card system which will add a new layer of
information for reporting to your hospital’s Trust Board, helping them
understand the detail of what is happening on wards
Board led walk rounds have begun, initiated by a patient story, so that you
and our staff can tell the Chief Executive, Chair and Directors your story
when they visit the ward
7)
Clinical Effectiveness: A&E target
o
Deliver on the four hour target in A&E: to ensure at least 95% of
patients attending the Emergency Department have been treated and
discharged from the department within four hours
What we did in 2012/13
The Trust successfully delivered the 95% four hour wait target in
2012/13. This was achieved through the hard work and dedication of
our teams and through joint working with our partners in the
community.
The Trust has invested in excess of £500k capital funding in the
redesign of the departments within Urgent and Ambulatory Care. The
building programme included:
o Increase in Emergency Assessment Unit (EAU) Bed Base (17 to 22)
o Phase 1 introduction of Clinical Decision Unit (CDU) (six Recliner
Chairs) to avoid unnecessary admissions for patients
o Creation of GP Assessment Area ( two GP Assessment Beds)
o Majors Area - Improvement in Patient Visibility (Removal of three
Cubicles and alterations to Assessment Area)
o Reconfigure Streaming and Rapid Assessment /Minors Area
o Entrance and Reception to enhance patient flow
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o Ambulatory Care Unit (an treatment area for patients that do not
normally require an inpatient stay) moved to the Urgent Care Centre
Building to enhance the patient environment
There has also been an emphasis on improving the system and
processes that will support this work:
o Reduction in number of Major Cubicles – the Emergency
Department had 17 Major cubicles. This has now reduced to 13 with
the creation of a central operational hub enabling more effective
communication, bringing the clinical team together and delivering
significant improvements to patient safety and the patient
experience
o Direct Assessment of GP Referrals in EAU - Medical referrals from
GPs now report directly to the EAU avoiding the need to go through
the A&E assessment process, as the GP has already made the
decision they need to be seen by a specialty doctor.
o Phase 1 of CDU is for patients who need a period of assessment
and observation greater than four hours before a decision to admit
or discharge can be made. This will include patients awaiting results
of investigation, CT, clinical observation and pain relief. The
expectation is that in excess of 80% of admissions will be
discharged home and the remainder transferred to EAU/ward with a
planned length of stay of less than 12 hours.
o Patient Journey Tracker (Navigator) - A new role developed to work
alongside the Shift Leader and Senior Doctor in Charge to `push
and pull` patients through the System. They work to an agreed set
of stage of treatment target times and escalation process.
o Chest Pain Pathway - The Clinical Service Group Leads for
Cardiology and ED have worked with the Laboratory to develop a
new Acute Chest Pain Pathway using the six Hour High-Sensitivity
Troponin test to rule out myocardial infarction (MI).
o Urgent Care Centre & Minors Pilot - the Pilot, which ran for four
weeks, brought together the skills and expertise of practitioners
employed by the Trust and the South Essex Partnership Trust to
simplify the patient journey, improve streaming to alternative points
of care and help shape the future urgent care delivery model. The
evaluation of the pilot will be subject to consideration by
Commissioners in West Essex and Hertfordshire.
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o Ambulatory Care - In November 2012 the Ambulatory Care Unit
(ACU) moved to its permanent base in the building previously
occupied by the Urgent Care Centre. It is an opportunity to relaunch the service and its initial focus will be improving delivery
against the 12 Best Practice Tariffs.
In addition to the changes already outlined to simplify the patient journey, a
number of additional measures are now in place to improve efficiency. These
include a review of medical and nurse staffing arrangements, which has seen
an increased consultant presence on the ‘shop floor’, with cover now between
the hour of 0900 and 2200 and often to 2400 hours, and nurse staffing rotas
matching known peaks in activity.
A daily ED Pathway Performance meeting has also been introduced with wide
representation from across the Trust.
The Trust has embarked on a significant transformation programme within the
Urgent and Ambulatory Care Units. The building programme has made
significant improvements to the environment as well as the patient journey
and patient experience. In addition, systems and processes have been
improved to support the changes. This, combined with the hard work and
dedication of our staff, has enabled the Trust to meet the national target.
What we plan to do in the next 12 months
The challenge for 2013/14 is to embed best practice with a continuous
improvement in the quality of care offered and sustain the performance achieved
in 2012/13. This will be achieved through continuous learning from complaints
and incidents and from patients’ comments and feed- back.
The move of the Ambulatory Care Unit to its permanent base has provided
an opportunity to re-launch the service and, in 2013/14, build on an
improving performance and increase the number and range of conditions it
is able to treat. For patients unable to access ACU, the development of
CDU (Phase 1) provides an opportunity to introduce new pathways to
avoid hospital admissions and treat patients in a more appropriate
environment. The development of Phase 2 of CDU would provide further
opportunities, especially for the frail and elderly and further work is
required on our Ambulatory Care environment.
Exploratory discussions around integrating a General Practitioner into ED,
especially out of hours and at weekends, has the potential to reduce
primary care presentations within ED. However safeguards must be
included to ensure patients do not see this as a means of bypassing
normal GP access.
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Building for Excellence
8)
Ensure we deliver Equality Objectives
We used multiple sources of information to develop our Equality Objectives for
2012/13 including, workforce reports, complaints records, the Essex Joint Strategic
Needs Assessment Report and third party reports e.g. The Care Quality Commission
(CQC) registration evidence, surveys of patients and staff experience. NHS Choices
and these are set out below:
i.
Staff awareness of issues relating to Equality Delivery System (EDS) and
how they contribute to its delivery at PAHT - 95% of staff to be aware of the
PAHT Equality Objectives by April 2013.
What we did in 2012/13 – the Trust still has some work to do to raise the
awareness of and embed the Equality Objectives into the organisational
culture and the mechanisms for measuring this need to be developed. As
part of our commitment to raising the awareness about equality and diversity
the Trust ran an Intercultural Awareness workshop from Muskaan, Dacorum
Pakistani Women's Group in Harlow, in which delegates at the workshop took
part in a quiz to explore what they know about other cultures and customs.
This generated a wide-ranging discussion as people asked the facilitators
about their cultural norms and practices and learnt how cultural attitudes
influence healthcare access, for example, how the wider family network can
influence a woman’s health choices. The session concluded with a look at
how health professionals can work in partnership with the Muslim, Indian &
Hindu Women's community to overcome barriers to care.
What we plan to do in the next 12 months – as part of the Trust’s
organisational development programme the Director of Nursing and Quality
will be re-launching the Equality Objectives as the Trust Lead for Equality and
Diversity.
ii.
‘Make Every Contact Count’ In our surrounding areas, there are significant
pockets of health issues directly related to the population. For example, there
are more people who smoke and drink in the area around this Trust than in
most parts of the country. The Trust can play a key role in the intervention of
those who need or are willing to give up smoking or reduce drinking by
providing advice to those individuals.
What we did in 2012/13 – the Trust Board signed up to the ‘Make Every
Contact Count’ initiative and approved a strategy to help patients stop
smoking and reduce drinking. Key to the strategy was the training of frontline
staff who would increase awareness of the support available to patients
during their contact. As a result the Trust saw referrals to smoking cessation
clinics rise from 120 in quarter one to 230 in quarter four of 2012/13.
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
What we plan to do in the next 12 months – we will continue to provide
information to our patients to make them aware of the support services that
are available to them.
iii.
Empower patients by providing adequate information before, during and
after visits to hospital:
a.
Reduce to national average the percentage of patients who report that
they had either ‘not enough or no information given about condition or
treatment’ by April 2013 and make incremental improvements to be in
the top 25 percentile within four years. Currently 22% of the Trust’s
patients answered ‘yes’ to this question compared to national average
of 16% for Acute Trusts, The PAH Outpatient Survey Report 2011.
What we did in 2012/13 – The Outpatient Survey will take place during
2013, however, the Inpatient Survey shows the Trust slightly improved
in this area from 2012 compared to 2011.
b.
Reduce to national average the percentage of patients who report that
‘not all staff introduced themselves’ by April 2013 and make
incremental improvements to be in the top 25 percentile within four
years. Currently 36% of the Trust patients answered ‘yes’ to this
question compared to the national average of 28% for Acute Trusts,
The PAH Outpatient Survey Report 2011.
What we did in 2012/13 – The Outpatient Survey will take place during
2013. The Trust’s drive to improve the patient experience is described
in detail within these Quality Accounts.
iv.
‘No decision about me without me’ - Reduce to national average the
percentage of patients who report that they were ‘not fully involved in decision
making about care and treatment’ by April 2013 and make incremental
improvements to be in the top 25 percentile within four years. Currently (34%
of the Trust patients answered ‘yes’ to this question compared to the national
average of 27% for Acute Trusts, The PAH Outpatient Survey Report 2011.
What we did in 2012/13 – The Outpatient Survey will take place during 2013.
The Trust’s drive to improve the patient experience is described in detail
within these Quality Accounts.
v.
Improved data collection. We aim to gain more complete data on sexual
orientation. At present, most Trusts are showing around 90% plus of either
‘Null’ or ‘Refuse to answer’. This means that we are unable to assess
whether or not our recruitment and HR processes are fair and open, and we
do not have a true picture of the diversity of our staff.
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
Our aim therefore is to understand the diverse nature of our staff in order to
meet their needs and create a more inclusive culture.
Our objective is to improve the data and increase declarations of sexual
orientation by staff by at least 10% within four years.
What we did in 2012/13 – The new Director of Human Resources was
appointed in year and has undertaken a review of the data available within the
organisation. Following this a Deputy Director of Human Resources has been
appointed and will lead on the improvement in the Trust’s workforce
informatics in line with our objective to promote equality and diversity in
conjunction with the Director of Nursing and Quality. The Trust will be aiming
for a 3.3% increase next year and for the following two years.
vi.
Address harassment, bullying or abuse from staff. The staff survey
illustrates that the Trust has not improved in this area from last year, and is
above the national average for acute Trusts. Therefore, the objective is to
reduce the percentage of staff experiencing harassment, bullying or abuse
from staff to below the national average by 3% over four years.
What we did in 2012/13 – the Trust has not improved in this area as
demonstrated by the staff survey. The new Director of Human Resources has
undertaken a review of the staff survey and this area falls under key priority
one. The Director of Human Resources is leading the staff improvement
programme and, together with the Director of Nursing and Quality, ensuring
that the values of the organisation are clear and identifiable to all staff.
Through the Achieving Excellence patient experience programme, patients
and carers are helping to define the service behaviours they expect from
every member of staff. The behaviours and values will be incorporated into
our recruitment, staff development and appraisal processes.
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
Other priorities from 2012/13
As a Trust we focussed on some key areas related to quality in addition to the
priorities we described last year:
Infection control
Performance against standards
There were challenging standards set by the Department of Health this year and the
Trust has not achieved the trajectory for Clostridium difficile (C. diff) and MRSA
bacteraemia. However, we were in the top seven performing Trust’s in England last
year in relation to Health Care Acquired Infections and only two acute trusts had a
lower target rate than PAHT.
MRSA
The Trust maintains a zero tolerance to MRSA bacteraemia. Each case is
scrutinised by a multidisciplinary team to identify root causes and ensure that
lessons learnt are shared widely across the organisation. The MRSA bacteraemia
rate remains extremely low with only two post 48 hour bacteraemia in year.
Clostridium difficile
There were 15 cases of C. diff against a trajectory of 14. In 2012/13 a period of
increased incidence of C diff cases occurred in October and November which
coincided with a norovirus outbreak. The period of increased incidence was
investigated and a comprehensive action plan was developed to address the findings
of the multidisciplinary team meeting. The Infection Control Nurse from the Strategic
Health authority, the Regional Epidemiologist and Acting Regional Epidemiologist
visited the Trust in January 2013. They spent the day at Princess Alexandra Hospital
and visited the wards and reviewed our processes for infection prevention and
control. They met with representatives from Pharmacy, Domestic Managers,
Executives, Ward Managers, Matrons, Clinicians and the Infection Control Team.
They found no gaps in infection prevention and control practice at the Trust and were
reassured that effective controls and surveillance were in place. They particularly
commended the data collection which is frequently disseminated widely in the Trust,
allowing real time monitoring and proactive controls.
Infection Prevention and Control 2013/14
In 2013/14 we have stretching infection control standards: 0 cases of MRSA and 9
cases of C. diff, amongst the most challenging targets in the country based on our
previous success. In order to maintain and further improve our excellent record on
infection prevention and control the Trust will be taking the following actions:
proposing changes to the MRSA suppression protocol to manage the High Level
Mupirocin Resistant strain of the bacteraemia
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
introducing regular hydrogen peroxide vapour cleaning and targeted cleaning in
areas where there have been cases of C. diff. The Trust is considering two
systems that are available on the market for effectiveness and ease of use
Cancer Services
Work to improve the delivery of our cancer services in line with national standards
continues. As a result the Trust is going through a period of great change, raising
the profile of Cancer Services. There is still significant work to be undertaken to
increase and embed this change to ensure that cancer care delivery is both patient
centred and timely. During the year there have been significant improvements in the
data capture and monitoring systems for patients on cancer pathways, providing the
Trust with much better oversight of the pathways and delivering a better patient
experience. The Trust has invested in additional administration support to the cancer
unit to aid the clinical teams and has co-located the Cancer Nurse Specialists and
Multi-Disciplinary Team Co-ordinators into one office to improve productivity.
Cancer 2013/14
The Intensive Support Team from the Department of Health was invited to work with
us in assessing the improvements we had made to the cancer service in early 2013.
The aim was to undertake a diagnostic assurance review of the Trust’s cancer
service and its approach to improving performance and delivering a sustainable
service. This review was to include an assessment of the Trust’s cancer systems,
processes and policies, an evaluation of the organisation’s responsiveness to
delivering timely cancer services, and to make recommendations for where things
could be improved.
When the findings from this report are published, alongside the peer review findings,
they will be used to make further improvements for cancer patients in the
forthcoming year. The Trust is undertaking an In Your Shoes event for cancer
patients as part of the Achieving Excellence programme. This event will be used to
gain insight into the current patient experience which will inform service
improvements for the year ahead. The Trust is part of a cancer network, London
Cancer, and we will be working with them on new developments during the coming
year. One of the areas of focus for London Cancer is work on proposals to centralise
the complex surgical elements of cancer treatments at designated cancer centres.
The benefit of these proposals is that they will deliver improved outcomes for
patients.
Electronic Patient Record (EPR)
In late 2012/13 the Trust agreed to invest in the delivery and on-going support of a
new Electronic Patient Record (EPR) system to replace the current Patient
Administration System. The Trust needs to take action at this time as the current
Patient Administration IT system will expire in March 2014 with no opportunity for
further renewal. The Trust is unable to operate without this system as many of the
clinical systems that depend on it are required to ensure patient safety and the
provision of care.
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
The EPR programme is an integral part of the Building for Excellence initiative at the
Trust. The implementation of a major IT solution on this scale will positively impact
clinical and administrative working practice across the entire organisation and have
benefits in the local care community. This presents an opportunity for us to
reconsider how we work in a number of areas and implement improvements. The
EPR programme is therefore an enabler for a wider transformation programme that
will allow considerable clinical and cost benefits to be realised.
The EPR programme also allows the Trust to fulfil the national information system
criteria for the NHS. A priority among these is the Clinical 5 mandate from the
Department of Health which calls for the following systems to be in place and will be
delivered by the Trusts new system:
A Patient Administration System (PAS) with integration to other systems and
sophisticated reporting
Order Communications and Diagnostics Reporting (including all pathology and
radiology tests and tests ordered in primary care)
Discharge Letters with coding (discharge summaries, clinic and Accident and
Emergency letters)
Scheduling (for beds, tests, theatres)
ePrescribing (including ‘To Take Out’ medicines)
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
Priorities for Quality Improvement in 2013/14
To support the achievement of our vision and to enable us to focus on delivery, we
set the following core set of governing aims:
1) Excellent safety and clinical outcomes for patients: benchmarked against
the best
2) Excellent experience for patients and their carers: delivering personalised
care
3) Excellent operational performance: meeting regulatory and national
operating standards
4) Excellent value: improving efficiency and productivity and reducing costs
5) Excellent morale and staff engagement: ensuring organisational health by
investing in our staff and infrastructure to ensure we are fit for the future.
These five overarching aims underpinned our work in 2012/13 and provided a
framework for the objectives that were set for the year, many of which we have
achieved. However, whilst these aims and objectives were in place, the Trust’s
number one priority remains patient safety.
Going forward into 2013/14 we have identified five improvement priorities and the
actions we will take towards achieving them. Progress against them will be reported
in next year’s Quality Accounts:
1) Improving patient safety and reducing the incidents of avoidable harm, as
measured by a 95% achievement each month of harm free care as
measured by the patient safety thermometer.
Implement an improved Trust Quality Governance framework for each
directorate
Use national programmes, such as the King’s Fund, to develop clinical
leadership in promoting patient safety and learning from incidents
Develop levels of responsibility for clinical leads to focus on programmes
across all services
Share performance of harm-free care in wards, units & departments
Integration of lay members onto all safety/ quality forums to promote challenge
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
2) Ensure that SHMI and HSMR are within the expected range with an overall
trajectory of improvement as reported by the NHS Information Centre. This
will include focussed attention on treatment and care of patients with
cardio-respiratory diseases and end of life pathways.
Improve escalation and clinical management of the deteriorating patient
Improve palliative care specialist advice to support patients, families and
clinicians in decision making and communications
Appoint a respiratory nurse specialist to lead on the implementation of the
Chronic Airways Disease discharge bundle
Establish clinical champion for medical documentation improvement work
stream
Adoption of integrated stroke pathway to deliver better patient outcomes in line
with national guidance
3) Improve patient experience as measured by 5% improvement in net
promoter score and improvement to the mid-range in the inpatient survey.
Formal launch of the Achieving Excellence patient experience improvement
programme and commencement of the In Your Shoes listening events for all
services with collated outputs presented across the Trust
Provide a suite of patient experience measures for services to support
improvement
Establish a Patient Panel as critical friends to support Quality Groups and to
provide challenge to the organisation
Thematic analysis of complaints, real time feedback at service level and action
change
4) Improve staff experience as measured by findings in the staff survey: Key
Finding 2 (staff agreeing that their role makes a difference to patients) and
Key Finding 24 (Staff recommendation of Trust as place to work or receive
treatment) scoring the national average or better.
Review organisational values and launch core behavioural standards,
including them within the recruitment and staff development processes
Launch a staff experience programme to support staff development and
improved quality of service delivery and patient experience
Develop criteria for staff awards aligned to behavioural and service standards
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
Embed new appraisal and personal development plan process
Undertake regular bi monthly staff surveys
5) Achieving and sustaining Emergency Department clinical standards as
measured by achievement of 95% target from quarter two onwards (93.6%
quarter one) and delivering clinical quality indicators at or better than
national average.
Addressing capacity constraints – develop nurse practitioner role
Ensure reliable discharge date prediction – continued application of Discharge
Jonah
Further develop ambulatory emergency care
Scope and pilot a Hospital at Home scheme
Implement Frail Elderly service at front door with system wide partners
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
Statements relating to quality of NHS Services
provided
A Review of Services
The Trust provides a range of services to a local population of 285,000 living in West
Essex and East Hertfordshire. The majority of services are provided from the main
hospital site in Harlow, but local hospitals in Bishop’s Stortford and Epping offer
outpatient and diagnostic services too. A small proportion of our patients were
treated at private hospitals in the local area due to extreme operational pressures.
The Trust provides a comprehensive range of general medical and surgical services
and has a busy Emergency Department (81,514 attendances in 2012/13), Intensive
Care Unit (9 beds) and Neonatal Unit (16 cots). The current list of service portfolio is
outlined below:
Medicine
Surgery
General Medicine
Trauma & Orthopaedics
Care of the Elderly Medicine
General Surgery
Gastroenterology
Breast Surgery
Respiratory Medicine
Urology
Cardiology
ENT
Rheumatology
Audiology
Dermatology
Ophthalmology
Diabetology and Endocrinology
Oral Surgery
GUM
Critical Care
Neurology
Anaesthetics
Cancer & Diagnostics
Women’s & Children’s Services
Haematology
Obstetrics
Medical Oncology
Community Midwifery
Chemotherapy
Gynaecology
Breast Screening
Family Planning
Cytology Screening
New Born Hearing Screening
Radiology
Paediatrics
Pathology
Respite care
Pharmacy
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
During 2012/13 The Princess Alexandra Hospital NHS Trust provided and/or
subcontracted elective surgery. The Princess Alexandra Hospital NHS Trust has
reviewed all the data available on the quality of care in the elective directorate.
The income generated by the NHS services reviewed in 2012/13 represents 99.6%
of the total income generated from the provision of NHS services by The Princess
Alexandra Hospital NHS Trust. The remainder came from training and education
contracts and Service Level Agreements with other providers.
The Trust has a service level agreement in place with subcontract providers for the
provision of services and has regular contact with them to agree levels, type and
timescales for patient treatment.
Clinical audit and research
During 2012/13 activity on Research and Development (R&D) in PAHT has
progressed in line with the Board approved R&D strategy and can be summarised as
follows:
During the year 2012/13 a total of 61 clinical trials have been active in the Trust. This
is a slight decrease in last year’s activity, however, the Trust has concentrated on
interventional trials rather than observational, driving the quality agenda forwards
and meeting the objectives of the National Institute for Health Research.
Of these, 52 were classified as portfolio studies (National Institute for Health
Research (NIHR) adopted studies) and 9 were non-portfolio studies of which 4 were
local activity.
Out of the total number of active studies, 10 were industry-sponsored studies. These
studies are potential income generating activity which contributes to the overall cost
of conducting R&D in the Trust. The R&D Strategy is currently being updated to
cover the period 2013-2018 with the emphasis being to work with the Anglia Health
Partnership to develop the Trust’s portfolio of Commercial activity. In 2012/2013 The
Princess Alexandra Hospital NHS Trust was recognised for being the best
performing Trust for commercial studies within the North London Cancer Research
Network.
Significant funding, related to level of research activity, to cover excess treatment
costs and resource support for portfolio research was received by the Trust from our
local Essex and Herts Comprehensive Local Research Network (CLRN) during
2012/13. This amounted to circa £230,000 and covered PA sessions for Principal
Researchers to contribute to research activity, research nurses to conduct the
research, support services resource funding to cover pathology, radiology and
pharmacy and site coordination of portfolio research activity.
During this year PAHT has recruited over 300 patients into active portfolio clinical
trials. This represents a success level in line with the target set at the beginning of
the financial year, and reflects the Trust’s commitment to clinical interventional
activity, bringing new procedures and treatments to the local population.
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
In line with the Trust’s R&D strategy, research activity in the trust has been extended
into clinical specialties previously research inactive. During 2012/13 clinical trials
were offered to suitable patients in the following specialties at PAHT:
Cancer
Haematology
Trauma & Orthopaedics
Rheumatology
Gastroenterology
Dermatology
Stroke
Critical Care
Neurology
Surgery
Women and Child Health
Pathology
Radiology
Support & Surgical Services with the North Essex Health Partnership NHS
Foundation Trust
Management of R&D within PAHT continues to be achieved through an R&D
Committee within the overall remit of the Medical Director. Research governance has
been maintained within the Trust throughout the year at a high level of efficiency and
diligence. There have been no significant breaches of research governance although
there has been one internal investigation conducted to eliminate the potential for
specific breaches related to patient safety to occur.
The process for obtaining local Trust approval for research studies continues to be
efficiently managed. The R&D function is part of a group working across the Essex
& Herts region together with the Anglia Health Partnership to pilot a ‘Harmonisation’
initiative which will involve single sign off systems for commercial trials in the first
instance, enabling fast and efficient set up times for research.
The Research department is committed to the Patient Engagement initiative and
have several sources of media across the Trust offering patients the opportunity to
participate in research, where available, for the treatment of their condition, and
encouraging feedback to improve services.
A Service Evaluation process has been developed to encourage all quality
improvement initiatives and covers the boundaries between Research, Innovation,
Clinical Effectiveness and Clinical Audit.
29
The Princess Alexandra Hospital NHS Trust
Building for Excellence
Participation in Clinical Audit 2012/13
During 2012/13 38 national clinical audits and three national confidential enquiries
covered NHS Services that the Trust provides.
During 2012/13 the Trust participated in 76% of national clinical audits and 100% of
national confidential enquiries that it was eligible to participate in.
See below for full details including:National clinical audits and national confidential enquiries in which the Trust
was eligible to participate.
National clinical audits and national confidential enquiries that the Trust
participated in and for which data collection was completed.
The Trust participated in 122 local audits during 2012/13, improving patient safety
and patient outcomes.
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
National clinical Audits in which the Trust was eligible to Participate
Subject
Participated Cases
Indicated or
Required
Cases
Submitted
% Cases
Submitted
Comment
Yes
All
375
100%
Awaiting Information
Yes
All
21
100%
Yes
All
All
100%
Epilepsy 12 – Royal
College of
Paediatrics and
Child Health.
Yes
All Cases
30
100%
National information received May, 2013 and is currently
being analysed.
Local Action Plan developed from the national report.
Service development initiatives include Discharge
Checklist, Sharing of Information with the Emergency
Department, Update of Asthma Guideline, Design
Patient/Parent information leaflets if there is none available
from the Asthma National Campaign, development of
Asthma Card/Management Guideline for parents and
School Plans.
The Trust was an early adopter site for this activity. Action
Plan in place to further develop services including the setup of local epilepsy database. All Paediatricians have
training and expertise in epilepsy to provide a secondary
level service for children with suspected/confirmed
epilepsy.
Paediatric Intensive
Care (PICANet)
Not
applicable
to the Trust
Peri and Neonatal
Neonatal intensive
and special care
(NNAP)
Children
Paediatric
Pneumonia (BTS)
Paediatric Asthma
(BTS)
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The Princess Alexandra Hospital NHS Trust
Building for Excellence
Paediatric Cardiac
Surgery (NICOR
Congenital Heart
Disease Audit)
Diabetes (RCPH
National Paediatric
Diabetes Audit)
Acute Care
Emergency Use of
Oxygen (BTS)
Adult Community
Aquired Pneumonia
(BTS)
Non Invasive
Ventilation – Adults
(BTS)
Cardiac Arrest (Nat
Cardiac Arrest
Audit)
Adult Critical Care
(ICNARC CMPD)
Not
applicable
to the Trust
Yes
All cases
All Cases
100%
Awaiting results from national report for 2012-13. National
audit activity results now available for 2010-2011 – report
published September 2012. No local specific activity
reported in this document, but Audit Lead is currently
developing a localised action plan to drive forward service
developments.
No
Data not submitted
No
Data not submitted
No
Data not submitted
Yes
All Adult inhospital
Cardiac
Arrest
Awaiting
Validation
Awaiting
Validation
Yes
All
273
Awaiting
Validation
National standardised audit of inpatient cardiac arrests
enabling improvements to patients at risk and improve
outcomes. Joint initiative between Resus Council and
ICNARC.
Suggested improvement initiatives are:
improvement of survival rates following cardiac arrest, data
to be used for planning resuscitation team responses, the
use of data to engage clinicians, managers and Trust
Board members.
Information available from 1.4.11 to 29.9.11 only at this
time. Promotion of evidence based practice, improving
32
The Princess Alexandra Hospital NHS Trust
Building for Excellence
Fractured Neck of
Femur – College of
Emergency
Medicine
Yes
All Cases
All Cases
100%
Feverish Children
Audit – College of
Emergency
Medicine
Yes
All Cases
All Cases
100%
Renal Colic –
College of
Emergency
Medicine
Yes
All Cases
All Cases
100%
Long Terms Conditions
Diabetes (Nat Adult No
Diabetes Audit)
Chronic Pain
Not
(National Pain Audit) applicable
to the Trust
Parkinson’s Disease No
(Nat Parkinson’s
Audit)
Adult Asthma (BTS) No
quality of audit and research in critical care. Comparative
data with similar sized units. Resource to enable various
research projects.
Local action plan presently being developed based on the
information provided in the national/localised report
received February, 2013.
Initial outlook is showing
significant improvement reported on offer/provision of
analgesia on arrival at Emergency Department and Pain
Score Recording.
Local action plan presently being developed based on the
information provided in the national/localised report
received February 2013.
Initial outlook is showing
significant improvement reported on vital signs measured
and recorded as part of the routine assessment.
Local action plan presently being developed based on the
information provided in the national/localised report
received February 2013. Data provided this year, where
in previous year this was not recorded therefore
comparable information cannot be measured.
Activity declared on audit plan but data submission did not
meet deadline.
No Service available.
Data not submitted.
Data not submitted.
33
The Princess Alexandra Hospital NHS Trust
Building for Excellence
Bronchiectasis
(BTS)
National
Inflammatory Bowel
Disease
Older People
National Audit of
Dementia
No
Data not submitted. Principal Auditor has left the Trust.
Yes
Unknown
Unknown
Unknown
Data Collection from January 2013 to December 2013
therefore information will not be available until 2014.
Yes
All Cases
All Cases
100%
National/localised report available for Round 1 of the audit
carried out in 2010/2011. Round 2 date was collected
between April and October 2012 and will be published in
July 2013. Information currently being developed into a
Local Audit Plan. Information available: Care Pathway is
currently in development
All Cases
All Cases
100%
*See note
in next
column.
Information from the registry database published annually
outlining a league table for these areas of surgery. This
information is used to help improve patient safety and
monitor the results of joint replacement surgery.
Information helps to find out which are the best performing
artificial joints and the most effective types of surgery.
Detailed information not available, however information
and data from the Co-ordinating centre has considerably
changed. Staff within Surgery & Critical are to undertake
training on how to use the system enabling analysis and
interpretation of data for future reporting.
Elective Procedures
Hip, knee and ankle Yes
replacement (Nat
Joint Registry)
Elective Surgery
(Nat PROMs
Programme) Hips
Yes
All Cases
unknown
Elective Surgery
(Nat PROMs
Yes
All Cases
Unknown
*Not all patients consent to completing the questionnaire.
*See note Detailed information not available, however information
in
next and data from the Co-ordinating centre has considerably
Column
changed. Staff within Surgery & Critical are to undertake
34
The Princess Alexandra Hospital NHS Trust
Building for Excellence
Programme) Knees
training on how to use the system enabling analysis and
interpretation of data for future reporting.
*Not all patients consent to completing the questionnaire.
Elective Surgery
(Nat PROMs
Programme) Hernia
Yes
100%
Unknown
*See Note
in next
column.
Detailed information not available, however information
and data from the Co-ordinating centre has considerably
changed. Staff within Surgery & Critical are to undertake
training on how to use the system enabling analysis and
interpretation of data for future reporting.
*Not all patients consent to completing the questionnaire.
Elective Surgery
(Nat PROMs
Programme)
Varicose Veins
Yes
100%
Unknown
*See note
in next
column
Detailed information not available, however information
and data from the Co-ordinating centre has considerably
changed. Staff within Surgery & Critical are to undertake
training on how to use the system enabling analysis and
interpretation of data for future reporting.
*Not all patients consent to completing the questionnaire.
Intra-Thoracic
Transplantation
(NHSBT UK
Transplant Registry)
Not
applicable
to the Trust
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Building for Excellence
Coronary
Angioplasty (NICOR
Adult Cardiac
Interventions audit)
Peripheral Vascular
Surgery (VSGBI
Vascular Surgery
database)
Not
applicable
to the Trust
Yes
AAA
41
Not
Available
The data for this enables the information collected in the
Emergency Department to be used to identify patients who
are not fit for surgery, creating a safer environment.
An Amputation Pathway and Champion has now been
appointed as a result of information from the data
collected.
Amputation
The waiting time patients now have to wait for a Vasoflow
study has now been reduced to one month and a simple
database created to collect all relevant information.
56
Further actions are currently being developed.
Infrainguinal 47
Bypass
Carotid
Interventions
(Carotid Intervention
Audit)
Yes
Not
available
23
Not
available
Cases still required submitting for this quarter. Information
published 6 monthly. Data has improved local services by
good communication with the TIA clinic, the team and
therefore the patient journey.
36
The Princess Alexandra Hospital NHS Trust
Building for Excellence
CABG and valvular
Not
surgery (Adult
Applicable
cardiac surgery
to the Trust
audit)
Cardiovascular Disease
Acute Myocardial
Yes
Infarction & Other
ACS (MINAP)
All
All
100%
All
73
94%
National report available with localised information for
2011/2012. Action plans currently under development.
Every patient who presents with this condition is submitted
for the purpose of the audit. Results are shared at the
MINAP annual Audit meeting in May of each year.
Principal Auditor left the Trust. Data not submitted.
Information from published findings from 2011/2012 and
the recommendations are currently being developed into a
strategic action plan.
Every patient presenting with a stroke. Results are shared
at local stroke meetings and at network meetings
nationally. Data for the last quarter of the year not
uploaded in time for the deadline.
Heart Failure (Heart
Failure Audit)
No
Acute Stroke
(SINAP)
Yes
Cardiac Arrhythmia
(Cardiac Rhythm
Management Audit)
Pulmonary
Hypertension
No
Principal Auditor left the Trust. Data not submitted.
Not
Applicable
to the Trust
Data presented from designated centres, this Trust is not
one of them.
37
The Princess Alexandra Hospital NHS Trust
Building for Excellence
Renal Disease
Renal Replacement
Therapy (Renal
Registry)
Renal
Transplantation
(NHSBT UK
Transplant Registry)
Cancer
Lung Cancer
(National Lung
Cancer Audit)
Not
applicable
to the Trust
Not
applicable
to the Trust
Yes
113 Cases
Bowel Cancer
(National Bowel
Cancer Audit
Programme)
Yes
145 Cases
Head & Neck
Cancer (DAHNO)
Yes
Unavailable
Oesophago-gastric
Cancer (National OG Cancer Audit)
Yes
All Cases
157 Cases
39%
Information published 2012, summarises the key findings
of the audit for patients diagnosed with lung cancer or
mesothelioma who were first seen in 2011. Action plan in
place reflecting national recommendations. Final data
quality check prior to submission for 2012/13 planned for
May 2013
57 Cases
39%
Information published 2012, includes patients who were
diagnosed between 1st August, 2010 and 31st July, 2011.
100% of cases reported were discussed at the MultiDisciplinary Team Meeting. Action Plan in place reflecting
national recommendations. Final data quality check prior
to submission for 2012/13 planned for August, 2013.
Unavailable Unavailable Information not yet available from 8th round audit until later
in the year. Can report on findings in the quality account in
2014. Final data quality check prior to submission for
2012/13 planned for October, 2013.
88
88
Information published 2012 using data collected on or after
1st April, 2011. On-line questionnaires were administered
online in February 2012 to all participating Trusts.
Findings of the audit suggest that progress has been made
38
The Princess Alexandra Hospital NHS Trust
Building for Excellence
in the organisation of services for oesophago-gastric
cancer over the last five years. Information published
covers the Cancer Network activity rather than individual
Trust information.
Final data quality check prior to
submission planned for September, 2013.
Trauma
Hip Fracture
(National Hip
Fracture Database)
Severe Trauma
(Trauma Audit and
Research Network)
Blood Transfusion
National
Comparative audit
of Blood
Transfusion: Audit
of Blood Sample
Collection &
Labelling
Yes
All Cases
Yes
Unavailable
Yes
32
All Cases
100%
Information from the registry database published annually
outlining a league table for these areas of surgery. This
information is used to help improve patient safety and
monitor the results of joint replacement surgery.
Information helps to find out which are the best performing
artificial joints and the most effective types of surgery.
Unavailable Unavailable Data collection commenced October 2012 once Principal
Auditor had been identified. Data capture ongoing and
information will be available later in the year.
32
100%
National report localised for the Trust using data submitted
during May, June and July 2012 and published December
2012. Local Action Plan currently being developed using
data from national report.
39
The Princess Alexandra Hospital NHS Trust
Building for Excellence
Potential Donor
(NHS Blood &
Transplant)
Yes
18
18
100%
Organ donation was considered in every case where Brain
Stem Death was either suspected or confirmed and was
offered to families in 100% of cases. One person received
a life-saving liver transplant, 2 people received kidney
transplants and are now free from the constraints of
dialysis. One patient received a double lung transplant.
Emergency Department activity is not included as
arrangements were made to transfer the patient to Critical
Care for clinical maintenance, observation, review and
formal testing.
National Confidential Enquiries in which the Trust was eligible to participate
Subject
Principal
Auditor
Participated
Cases
Submitted
% Cases
Submitted
Yes
Cases
Indicated
or
Required
1
NCEPOD:
Subarachnoid
Haemorrhage
NCEPOD:Cardiac
Arrest Procedures
NCEPOD:
Bariatric Surgery
Dr Okeke
1
100%
Helen
Webber
Marcelle
Michail
Yes
2
2
100%
N/A
Dr. J.
McKenzie
Yes
Completed Organisational
Questionnaire as Trust has
Emergency Dept
2
2
100%
NCEPOD:Alcohol
Related Liver
Disease
40
The Princess Alexandra Hospital NHS Trust
Building for Excellence
Care Quality Commission
The Care Quality Commission is the independent The Trust is required to register
with the Care Quality Commission (CQC) and its current status is registration
without conditions. The Care Quality Commission has not taken enforcement
action against the Trust during 2012/13.
The CQC check compliance with the essential standards of quality and safety which
consist of 28 regulations. For each regulation there is an associated outcome.
When the CQC check compliance with the essential standards, they focus on the 16
Regulations that most directly relate to the quality and safety of care. These are:
Outcome Regulation
Title
1
17
Respecting and involving people who use services
2
18
Consent to care and treatment
4
9
Care and welfare of people who use services
5
14
Meeting nutritional needs
6
24
Cooperating with other providers
7
11
Safeguarding people who use services from abuse
8
12
Cleanliness and infection control
9
13
Management of medicines
10
15
Safety and suitability of premises
11
16
Safety, availability and suitability of equipment
12
21
Requirements relating to workers
13
22
Staffing
14
23
Supporting workers
16
10
Assessing and monitoring the quality of service provision
17
19
Complaints
21
20
Records
The Trust started the 2011/12 period with five Moderate Concerns and one Minor
Concern.
41
The Princess Alexandra Hospital NHS Trust
Building for Excellence
In July 2012 the CQC made a further unannounced visit to the Emergency
Department to check that the Trust had implemented the actions it had identified to
address the Concerns raised during the March 2012 visit. They reviewed the Trusts
compliance against Outcomes 1, 4, 13, 14 and 16.
The CQC checked our records, observed how people were being cared for, talked to
staff and talked to people who use the services. They found the Trust to be
compliant with all Outcomes with the exception of Outcome 4 where Minor Concerns
were identified. The CQC reported that the Trust had made improvements and is
continuing to develop access to specialist services. However, further and sustained
action was required to ensure that outcomes for all patients continued to improve.
In February 2013, the CQC requested an update on actions taken to address the
Moderate Concern against the Termination of Pregnancy Service and the Minor
Concern in the Emergency Department.
The Trust was able to demonstrate that it was compliant with the standards required
for the Termination of Pregnancy Services and that compliance was being sustained.
With the Minor Concern remaining in the Emergency Department, the Trust was able
to demonstrate that action had taken place to improve access to specialist services
and acknowledged that further work was required and continues to be monitored for
implementation.
The Trust monitors compliance with the CQC Outcomes by having identified CQC
Leads in each Directorate. Their role is to monitor levels of compliance and provide
assurance; any areas of concern identified are assessed and managed in
accordance with the Trusts Risk Management Strategy.
Summary of Care Quality Commission Concerns
Date
Outcome No.
Concern Level
Date Resolved
November 2011
13
Minor
The Trust
continues to
implement a
remedial action
plan
March 2012
21
Moderate
Evidence of
compliance sent to
CQC February
2012
March 2012
4
Moderate
September 2012
March 2012
13
Moderate
September 2012
March 2012
14
Moderate
September 2012
42
The Princess Alexandra Hospital NHS Trust
Building for Excellence
March 2012
16
Moderate
September 2012
September 2012
4
Minor
The Trust
continues to
implement a
remedial action
plan
Use of CQUIN Payment Framework
As part of the Department of Health’s (DH) commissioning for quality and innovation
(CQUIN) initiative, a significant and increasing proportion of the income for all NHS
Trusts in England is dependent on achievement of quality improvement and
innovation goals which are agreed between a trust and its commissioners.
For 2012/13 The Princess Alexandra Hospital NHS Trust agreed with its
commissioners, West Essex Clinical Commissioning Group and East and North
Herts Clinical Commissioning Group that 2.5% (approximately £3.6m) of the Trusts
income would be dependent on achievement of the CQUIN schemes. The schemes,
which are summarised below, were selected to incentivise improvements in areas of
concern for the Trust, local health economy and also nationally, as directed by the
Department of Health:
Improving patient experience
Improving the way we manage medicines at the Trust
Reducing the number of patients suffering from cardiac arrests in hospital
Reducing the number of avoidable pressure sores that arise within the hospital
Screening patients for risk of clotting and providing preventive treatment to those
at risk
Providing advice to patients on giving up smoking and/or reducing drinking
Improving the identification of patients with dementia and ensuring their needs
are met
Improving the number of patients who would recommend the hospital to their
friends and family
Auditing the delivery of harm free care
Specialist Commissioning standards relating to neonatal care
A proportion of The Princess Alexandra Hospital NHS Trust’s income in 2012/13 was
conditional on achieving quality improvement and innovation goals between The
Princess Alexandra Hospital NHS Trust and any person or body they entered into a
contract, agreement or arrangement with for the provision of NHS services, through
the Commissioning for Quality and Innovation payment framework.
Further details of the agreed goals for 2012/13 and for the following twelve-month
period are available electronically at www.pah.nhs.uk
43
The Princess Alexandra Hospital NHS Trust
Building for Excellence
The areas agreed for 2013/14 are summarised as follows:
1) Improving the identification of patients with dementia and ensuring their needs
are met
2) Reducing the number of falls and pressure sores that arise within the hospital
3) Screening patients for risk of clotting and providing preventive treatment to those
at risk
4) Improve the number of patients who would recommend the hospital to their
friends and family
5) Training and education of patient facing staff providing end of life care
6) Improve the identification of deteriorating patients and ensure effective
intervention
7) Ensure patients with exacerbated COPD are discharged from hospital with a
completed care bundle
8) Improve processes for discharge from hospital
Stroke Service
The Stroke Unit at PAHT has not achieved the required standards in the services it
provides and the Trust is working hard to improve the service in a number of areas.
The Trust is taking the following actions to improve the quality of the services it is
offering to stroke patients:
Stroke Consultants are providing training to the ED staff on early identification of
stroke patients and the Trust is implementing a new Integrated Care Pathway
that will highlight stroke symptoms to trigger early referral for admission to the
Stroke Unit.
The Trust is working with the Stroke Network to identify alternative providers that
are designated High Acuity Stroke Units to support and provide the thrombolysis
service. This will mean that more patients are able to receive thrombolysis at the
right time and in the right place but the majority of breaches of this standard
relate to poor public awareness of the symptoms of stroke. The Trust will be
working with its partners in the local health economy to try and improve public
awareness.
The Trust has increased the high risk transient ischaemic attack review clinic
capacity and is now running six days a week. A Stroke Consultant of the week
model is also in place which means that one consultant is available to treat
emergency admissions and the other consultants are then able to concentrate on
providing input into clinics. Work with High Acuity Stroke Units is ongoing to
provide weekend referral centres.
44
The Princess Alexandra Hospital NHS Trust
Building for Excellence
Never Event
The Trust reported one never event in 2012/13. This was where a retained foreign
body was found in a patients wound post-operatively. The object was a small piece
of surgical glove that had been damaged during a procedure. The Trust cannot be
certain that the Never Event took place at the Trust as the patient had undergone
surgery at another provider as well. However, given the serious nature of Never
Events the Trust raised this issue as an incident to ensure that any learning from the
event could be embedded within the Trust’s processes to avoid future reoccurrence.
Following a comprehensive investigation the Trust identified that it whilst it had
indicator gloves available it did not have a Standard Operating Procedure (SOP) in
place to ensure that these were used. Indicator gloves are used for certain
procedures where there is a requirement for the surgeon to wear two pairs of
surgical gloves. The indicator glove is a different colour from the top glove and has
been proven to improve the detection of damage to the top glove. The Trust now
has an SOP in place so that indicator gloves are worn for the appropriate
procedures.
Statement on Relevance of Data Quality
The Princess Alexandra Hospital NHS Trust will be taking the following actions to
improve data quality:
Introduction of an Electronic Patient Record system to replace the Trust’s existing
technology which will no longer be supported in 2014.
Regular reporting on data quality issues to the Information Governance Steering
Group via the Trust’s Data Quality Group and directorate Data Quality SubGroups.
Continue clinical validation of medical records coding to ensure accuracy of data
for national and local benchmarking.
The use of data quality risk registers to manage data quality risks/issues and
monitor the actions the Trust takes to mitigate those risks.
Data quality metrics and processes
NHS Number and General Medical Practice Code Validity
The Princess Alexandra Hospital NHS Trust submitted recordings during 2012/13 to
the Secondary Users Service for inclusion in the Hospital Episode Statistics, which
are included in the latest published data.
The percentage of records in the published data which included the patient’s valid
NHS number was (national average in brackets):
45
The Princess Alexandra Hospital NHS Trust
Building for Excellence
99.6% for admitted care (99.1%)
99.8% for outpatient care (99.3%)
98.2% for accident and emergency care (95.1%).
which included the patient’s valid General Medical Practice Code was:
100% for admitted patient care (99.9%)
99.8% for outpatient care (99.3%)
100% for accident and emergency care (99.7%)
Information Governance Toolkit Attainment Levels
The Trust is showing an overall score of 64% for the final declaration against the
Information Governance Toolkit at year end compared to 72% last year.
Trusts are required this year to have achieved a minimum of level two against all the
standards within the toolkit. The Trust still has 11 areas where we are only scoring a
level one, though the Trust has achieved level three against some of the standards.
This means that the Trust is rated as non-compliant. An Internal Audit report was
carried out on our compliance with the toolkit to assist in the development of our
action plan.
Table of IG incidents
Incident
Date
Directorate
Location exact
Category
June
Women &
Children’s
Birthing Unit
Breach of Confidentiality
June
Clinical Support
Services
Medical Secretaries
Breach of Confidentiality
July
Women &
Children’s
Birthing Unit
Information Governance
August
Cancer & Core
Restaurant
Breach of Confidentiality
August
Clinical Support
Services
Patient Contact
Centre
Failure to follow process
(IG)
October
Cancer & Core
WDU
Breach of Confidentiality
November
Cancer & Core
Radiology
Failure to follow process
November
Cancer & Core
Radiology
Failure to follow process
November
Women &
Children’s
Antenatal Clinic
Breach of Confidentiality
46
The Princess Alexandra Hospital NHS Trust
Building for Excellence
November
Medicine
Other Place (Patient
Home)
Breach of Confidentiality
November
Cancer & Core
DVT Team
Breach of Confidentiality
February
Medicine
Locke
Breach of Confidentiality
To improve the Information Governance position for both increasing toolkit
compliance and reducing incidents a detailed action plan has been put into place
and reported to the Board and its Standing Committees to ensure full compliance in
2013/14. Staff and managers are being held to account to ensure improved
performance.
Clinical coding error rate
The Princess Alexandra Hospital NHS Trust was last subject to a payment by results
clinical coding audit in 2012/13, this being undertaken by Capita on behalf of the
Audit Commission. The areas covered by the audit were lobar pneumonia with major
complications in admitted patient care and selected HRGs from Obstetrics in
admitted patient care. The error rates reported at that time for diagnosis and
treatment coding were:
Table 1: Full audit results for lobar pneumonia with major complications in admitted
patient care
Clinical coding
% diagnoses
incorrect
Other data items
% procedures
incorrect
Spells
tested
% of
spells
changing
payment
% of
spells
changing
HRG
%
clinical
codes
incorrect
Primary
Secon
dary
Primary
Secon
dary
% spells
with
other
data
items
incorrect
43
2.3
2.3
8.5
16.0
8.1
5.0
2.9
0.0
% other
data
items
incorrect
0.0
Table 2: Full audit results for targeted sample selected HRGs from obstetrics in
admitted patient care
Clinical coding
% diagnoses
incorrect
Other data items
% procedures
incorrect
Spells
tested
% of
spells
changing
payment
% of
spells
changing
HRG
%
clinical
codes
incorrect
Primary
Secon
dary
Primary
Secon
dary
% spells
with
other
data
items
incorrect
49
10.2
10.2
9.7
17.0
11.6
4.0
5.5
0.0
The Trust has an action plan in place to address the recommendations arising from the
audit.
47
The Princess Alexandra Hospital NHS Trust
% other
data
items
incorrect
0.0
Building for Excellence
Review of Quality Performance
How the Trust identifies local improvement priorities
The Trust works extremely hard to establish key areas of improvement –through
engagement with patients and staff and by benchmarking itself against other
healthcare providers.
This section highlights a number of examples where
improvements in quality have come as a direct result of collecting feedback through
various channels. These routes are in addition to the various patient surveys and
the net promoter patient feedback system on the wards, also highlighted in this
report.
NHS Choices, patient comment cards, external patient forums and staff engagement
exercises are all used to highlight areas of weak service. These are then fed down
through the organisation in a number of ways – through a management cascade or
through Trust-wide communications such as the InTouch Weekly newsletter and the
global email system.
Areas of improvement and development across the Trust
Other developments in 2012/13
Investment in Radiology - new Computerised Topography scanner (CT), digital xray room, new interventional radiology suite
Successful bid to the Department of Health to improve the Birthing Unit and
Labour Ward environment
Reconfiguration of departments within Urgent and Ambulatory Care
Work with South Essex Partnership Trust to integrate the Urgent Care Centre into
the wider Emergency Department
Establishment of the Serious Clinical Incident Group, taking a multidisciplinary
approach to reviewing serious incidents
Key appointments made in Patient Safety and Quality: Director of Nursing and
Quality, Head of Patient Experience and Head of Patient Safety and Quality
Introduction of electronic reporting of incidents on Datix
Establishment of a Patient Panel
Renovation and expansion of the discharge lounge
48
The Princess Alexandra Hospital NHS Trust
Building for Excellence
Development of the Trust’s Clinical Service Strategy - A Year of the
Clinically-led Team
Overall the first full year of clinical leadership has seen significant benefits to the
Trust. We have successfully embedded the structure throughout the clinical
directorates and it is clear that we have dedicated and hard-working senior clinical
management teams in those directorates with the Clinical Director, Clinical Service
Group Leads, Head of Operations and Head of Nursing posts working cohesively.
Through the clinical leadership within directorates and across the organisation the
Trust has seen the successful delivery of several initiatives in year including:
maintaining CNST level 2 in maternity
completing the building works on budget in Urgent and Ambulatory Care
improved performance in VTE risk assessments during the latter part of the year
maintaining high quality infection prevention and control
As part of the continuing development of our clinical structures the Trust will be
moving to a new structure of Clinical Improvement Groups at specialty level. This
will ensure that Clinical Service Group Leads are engaged in assuring patient safety,
a good patient experience and clinical effectiveness at service level. The Clinical
Improvement Groups will underpin the work on quality and safety at an
organisational level and will have a key role in leading quality improvements within
the services and specialties. The work will engage staff both clinical and managerial,
cascade best practice and learning from incidents, and escalate issues and provide
assurance up the organisation’s governance structure.
Report on Complaints
Achieving Excellence through Patient Experience
The total number of complaints has fallen by 41% this year to 470 cases compared
to last year when there were 665 complaints.
In 2012/13 44% (n=211) of complaints were closed within 28 days against 59% in
2011/12, 11.7% (n=55) of which took more than three months to achieve resolution.
A new approach to complaint resolution led by a new team, where directorates are
responsible for investigating and responding to complaints is now in place. This
process began in the second quarter of 2012/13. In addition to this many more cases
are now handled within 48 hours by the Patient Advice and Liaison Service (PALS)
which has seen a large increase in activity.
The percentage of complainants who remain ‘unsatisfied’ following an initial
response in 2012/13 is similar to 2011/12, at 12%. The Trust has opened up access
to the complaints and PALS processes by offering early meetings with clinicians for
49
The Princess Alexandra Hospital NHS Trust
Building for Excellence
patients and families and we have encouraged complainants to come back to us to
resolve any outstanding issues through meetings. However, as noted above, this has
continued to see a month by month fall in complaints.
This approach is reflected in the data on second stage resolution which happens
when a patient contacts the Parliamentary and Health Service Ombudsman. Of the
470 complaints we received in 2012/13 19 requested a second stage review, of
these one complaint was upheld. The case which was upheld was regarding a delay
in treatment which the Trust accepted. These figures may change as more cases are
referred and closed in the coming year. However, this figure is broadly in line with
findings from previous years.
Subject of Complaints
The subject of complaints has changed as the year has progressed. Although
communication issues were the primary and consistent concern alongside clinical
expectations at the beginning of the year, in the latter part of the year clinical
expectations and attitude have emerged as the more visible areas of concern.
50
The Princess Alexandra Hospital NHS Trust
Building for Excellence
Compliments
In 2012/13, as well as recording complaints, the Patient Experience Team has
developed
new
processes,
such
as
a
specific
email
address
(compliments@pah.nhs.uk), to record compliments. This has emerged as one of the
key pieces of information used to track the quality of the patient experience at The
Princess Alexandra Hospital NHS Trust.
Below is a wordle (a word cloud) showing the words used by patients when
complimenting staff. This wordle has been created by taking every single one of the
902 compliments and turning them into this image. The size of each word is in
proportion to the frequency with which it was mentioned in our compliments.
1: Wordle showing the
words used by patients
to positively comment
on the care they
received. A larger word
means the word was
used more often in
compliments
51
The Princess Alexandra Hospital NHS Trust
Building for Excellence
2: Graph showing
the number of
compliments
contrasted with the
number of
complaints in
2012/13
52
The Princess Alexandra Hospital NHS Trust
Building for Excellence
Performance against key national priorities 2012/13
National Priority
Target
PAH
Achievement
A&E four hour wait
95%
95.06%
RTT Admitted
90%
93.44%
RTT Non-Admitted
90%
97.95%
Clostridium difficile
14 cases
15 cases
MRSA
0 cases
2 cases
all cancers
93%
91.2%
for symptomatic
breast patients
(cancer not initially
suspected)
93%
92.3%
Surgery
94%
96.1%
Anti-cancer drug
treatments
98%
99.5%
From urgent GP RTT
85%
80%
90%
97%
96%
98.3%
Venous Thromboembolism (VTE) Screening
95%
93.63%
Elective MRSA Screening
100%
99.34%
Non Elective MRSA Screening
100%
96.96%
Cancer: two week
wait from referral to
date first seen,
comprising:
All cancers: 31-day
wait for second or
subsequent
treatment,
comprising:
All cancers: 62-day
wait for first
treatment,
comprising:
From consultant
screening service
referral
All Cancers: 31-day wait from diagnosis to
first treatment
The Trust has described within these Quality Accounts the detail of how it intends to
improve performance where it fell short of the standards for national priorities.
53
The Princess Alexandra Hospital NHS Trust
Building for Excellence
Indicator
Clostridium
difficile
MRSA
All
cancers:
31-day wait
for second
or
subsequent
treatment,
comprising
either:
All cancers:
62-day wait
for first
treatment,
comprising
either:
Sub
Sections
Are you
below the
ceiling for
your monthly
trajectory?
Are you
below the
ceiling for
your monthly
trajectory
Thre
shold
April
2012
May
2012
Jun
2012
July
2012
Aug
2012
Sept
2012
Oct
2012
Nov
2012
Dec
2012
Jan
2013
Feb
2013
Mar
2013
14
Yes
Yes
Yes
No
Yes
Yes
No
No
No
Yes
Yes
Yes
2
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
Yes
No
Yes
No
No
Yes
No
No
No
Yes
No
No
Yes
Yes
No
No
Surgery
94%
Anti-cancer
drug
treatments
98%
Radiotherapy
94%
From urgent
GP RTT
85%
From
consultant
screening
service
referral
90%
54
The Princess Alexandra Hospital NHS Trust
Building for Excellence
Indicator
Sub
Sections
Thre
shold
April
2012
May
2012
Jun
2012
July
2012
Aug
2012
Sept
2012
Oct
2012
Nov
2012
Dec
2012
Jan
2013
Feb
2013
Mar
2013
90%
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
95%
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
96%
Yes
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No
No
Yes
RTT
waiting
times –
admitted
Maximum
time of 18
weeks
RTT
waiting
times –
nonadmitted
All
Cancers:
31-day wait
from
diagnosis
to first
treatment
Maximum
time of 18
weeks
Cancer: 2
week wait
from
referral to
date first
seen,
comprising
either:
all cancers
93%
for
symptomatic
breast
patients
(cancer not
initially
suspected)
93%
Total time in
A&E
(95th
percentile)
≤4
hrs
A&E (Q1):
Total time
in A&E
55
The Princess Alexandra Hospital NHS Trust
Building for Excellence
Performance against local quality indicators in 2012/13
Unit
Apr
2012
May
2012
June
2012
Jul
2012
Aug
2012
Sept
2012
Score
107.0
3
107.
03
107.0
3
106.1
7
106.1
7
106.
17
Venous
Thromboembolism
(VTE) Screening
%
94.98
%
94.7
%
91.1
%
90.4
%
90.4
%
90.7
9%
Elective MRSA
Screening
%
98.9%
99.1
%
99.4
%
99.12
%
99.7
%
Non Elective MRSA
Screening
%
92.5%
93.8
%
96%
97.6
%
Number
3
0
0
Number
29
38
‘Never Events’ in
month
Number
0
CQC Conditions or
Warning Notices
Number
0
Criteria
SHMI
Single Sex
Accommodation
Breaches
Open Serious
Incidents Requiring
Investigation (SIRI)
Oct
2012
M
a
r
Nov
2012
Dec
2012
Jan
2013
Feb
2013
Mar
2013
92.8
%
95.48%
95.7
6%
95.88
%
95.91
%
95.7
7%
99.4
1%
99.2
%
99.9%
99.7
3%
99.5
%
99.3%
98.8
%
97.45
%
97.0
4%
97.8
7%
97.1%
99.8
4%
97.79
%
98.43
%
98.5
%
0
0
0
0
0
0
0
0
0
24
27
30
29
30
44
42
54
65
43
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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Unit
Apr
2012
May
2012
June
2012
Jul
2012
Aug
2012
Sept
2012
Oct
2012
Number
1
3
0
0
0
0
Number
0
1
2
1
0
Number
1
4
0
1
Grade 3 or 4
pressure ulcers
Number
7
2
3
100% compliance
with WHO surgical
checklist
Yes/No
Y
Y
Formal complaints
received
Number
44
%
%
Criteria
Central Alert
System (CAS)
Alerts
RED rated areas on
your maternity
dashboard?
Falls resulting in
severe injury or
death
Agency and bank
spend as a % of
turnover
Sickness absence
rate
M
a
r
Nov
2012
Dec
2012
Jan
2013
Feb
2013
Mar
2013
0
0
0
0
0
0
6
4
3
3
5
2
4
1
2
0
3
3
1
2
3
7
7
6
7
6
4
10
8
15
N
Y
N
Y
N
Y
Y
Y
Y
Y
40
52
47
52
42
33
31
39
28
35
28
5.92%
7.22
%
6.08
%
6.79
%
6.56
%
5.32
%
5.56
%
6.41%
4.7%
4.8%
5.46%
6.28
%
4.19%
4.42
%
4.34
%
4.31
%
4.03
%
4.06
%
4.79
%
4.09%
3.92
%
4.73
%
4.32%
4.54
%
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Summary of indicators
NHS Outcomes
Framework domain
Indicator
PAH
Score
2011/12
PAH
Score
2012/13
National
Average
Highest
Trust
Lowest
Trust
Summary Hospital-Level
Mortality Indicator (SHMI):
Domain 1: Preventing
people from dying
prematurely Summary
Hospital-Level Mortality
Indicator (SHMI):
SHMI value (and banding)
1.0605
Percentage of admitted
patients whose treatment
included palliative care
0.73%
Patient reported outcome
scores for i) groin hernia
surgery, ii) varicose vein
surgery, iii) hip
replacement surgery, and
iv) knee replacement
surgery
i) 0.080
ii) 0.080
iii) 0.388
iv) 0.290
Domain 3: Helping people
to recover from episodes of
ill health or following injury
Emergency readmissions
to hospital within 28 days
of discharge:
i) 0 to 15
ii)15 and over
i) 5.85
ii) 12.12
(2010/11)
Domain 4: Ensuring that
people have a positive
experience of care
Responsiveness to
inpatients’ personal needs
69.8
Domain 3: Helping people
to recover from episodes of
ill health or following injury
1.0617*
(2)
(Oct 11Sept 12)
1.000 (2)
(Oct 11Sept 12)
1.2107 (1)
(Oct 11Sept 12)
0.6849 (3)
(Oct 11Sept 12)
0.48%
1.16%
#
#
i) #
ii) #
iii) 0.442
iv) 0.328
(all Apr –
Dec 12)
i) 124
ii) 3541
(Trust data
12/13,
actual
numbers)
i) 0.090
ii) 0.090
iii) 0.429
iv) 0.338
(all Apr –
Dec 12)
i) 0.127
ii) 0.138
iii) 0.5
iv) 0.395
(all Apr –
Dec 12)
i) 0.017
ii) 0.027
iii) 0.328
iv) 0.201
(all Apr –
Dec 12)
i) 10.15
ii) 11.42
(2010/11)
i) 16.06
ii) 15.33
(2010/11)
i) 3.19
ii) 6.31
(2010/11)
#
#
#
75.6
(2011/12)
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Domain 4: Ensuring that
people have a positive
experience of care
Staff who would
recommend the provider
to friends or family
needing care (score out of
5)
Domain 5: Treating and
caring for people in a safe
environment and protecting
them from avoidable harm
Percentage of admitted
patients risk-assessed for
Venous
Thromboembolism
Domain 5: Treating and
caring for people in a safe
environment and protecting
them from avoidable harm
Rate of Clostridium difficile
per 100,000 bed days
Domain 5: Treating and
caring for people in a safe
environment and protecting
them from avoidable harm
3.5
Q1: 90.6
Q2: 92.2
Q3: 91.9
Q4: 92.6
3.35
3.57
4.08
#
93.6
90.5
94.6
95.9
93.4
93.9
94.2
94.3
100
100
100
100
80.8
80.9
84.6
87.9
21.8
(2011/12)
51.6
(2011/12)
0.0
(2011/12)
14.44
(Medium
Acute, Apr
– Sept 12)
3.11
(Medium
Acute, Apr
– Sept 12)
1.6 (Trust
as above)
0.7 (Trust
as above)
#
Rate of patient safety
incidents per 100
admissions
Percentage resulting in
severe harm or death
10.2
(The
Trust had
15 cases)
7.6
7.14
(Apr –
Sept 12)
1.81
0.3 (Apr –
Sept 12)
(0.2 12/13
Trust data)
#
#
Key
Trust data has used local data where Health and Social Care Information Centre data is not available or to supplement HSCIC data
* within the expected range
# data not available from Health and Social Care Information Centre
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External Audit Opinion on the Quality Accounts 2012/13
INDEPENDENT AUDITORS’ LIMITED ASSURANCE REPORT TO THE DIRECTORS
OF THE PRINCESS ALEXANDRA HOSPITAL 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 Princess Alexandra Hospital 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 readmitted within 28 days.
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:
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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.
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 received in June 2013;
feedback from Local Healthwatch dated 17 May and 17 June 2013 respectively;
the Trust’s complaints report published under regulation 18 of the Local Authority, Social Services
and NHS Complaints (England) Regulations 2009;
the latest national patient survey carried out by the Care Quality Commission between September
2012 and January 2013;
the latest national staff survey conducted by the Care Quality Commission for 2012;
the Head of Internal Audit’s annual opinion over the trust’s control environment dated 18 April
2013;
the annual governance statement dated 6 June 2013;
Care Quality Commission quality and risk profiles dated 31 March 2013; and
the results of the Payment by Results coding review dated 31 May 2013.
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 Princess Alexandra
Hospital 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 Princess Alexandra Hospital NHS Trust for our work or this report save
where terms are expressly agreed and with our prior consent in writing.
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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
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 non-mandated
indicators which have been determined locally by The Princess Alexandra Hospital NHS Trust.
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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.
Signed
Graham Nunns
Senior Statutory Auditor
for and on behalf of Grant Thornton UK LLP
Grant Thornton House
Melton Street
Euston Square
London
NW1 2EP
28 June 2013
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Statements from our Stakeholders and Commissioners regarding
the final report
Amendments to the Quality Accounts following feedback
Following the feedback from our stakeholders the Trust has made the following
amendments to the information in its Quality Accounts:
Further details on the plans to reduce serious incidents of avoidable falls and
avoidable pressure ulcers
A summary of the Never Event and the plans to prevent any reoccurrence
A summary of the improvement plan for stroke services
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Healthwatch Hertfordshire response to Princess Alexandra Hospital NHS Trust
(PAH) Quality Accounts for 2012 to 2013
PAHT has provided a comprehensive Quality Account that clearly sets out what the
priorities are, how they are being addressed and their ambition for the future. Those that
have not been achieved will be carried forward for further work.
The Trust has done well to achieve the 95% four hour wait standard in Accident and
Emergency by introducing a number of measures that staff have worked hard on to make a
success. We hope that this can be maintained without any loss in quality of care.
The Trust should be congratulated for being one of the ‘best performing organisations in
England’ for preventing Health Care Acquired infections with challenging targets set by
the Department of Health for this year and the coming year.
The statement from the Chief Executive mentions that the Board committee structure has
been reviewed and we would have liked to have had a little more information about how
this has been done in the Quality Account.
It is worrying that the Trust has not improved the issue of harassment, bullying or abuse
from staff and that it is currently above the national average for acute Trusts (results from
the staff survey). It is good therefore that staff experience has been chosen as a priority
for 2013/14 as staff satisfaction does have an impact on the quality of patient care. A
clear supportive policy statement on how whistle blowers are treated in the report would
also have been helpful.
We note the Care Quality Commission inspections and the action that has been taken as
well as the remaining minor concern for Outcome 4 relating to the Emergency
Department. More details about the further work required could have been provided in the
penultimate paragraph in this section.
Though the Information Governance requirements have increased, it is still disappointing
that the Trust is rated as non-compliant and we look forward to an improved result next
year once the action plan has been fully progressed.
The implementation of the QFI Discharge Jonah system to transform the discharge process
and promote a more joined up approach to patient care sounds as if it is beginning to
make an impact. We would very much like to understand how it is supporting
Hertfordshire residents who need social care in place when they leave hospital.
The work that the Trust has carried out to meet the needs of those with learning
disabilities or autism is to be commended. We have received some very complimentary
feedback on the care and professionalism of the LD nursing team and other hospital staff
to support both patient and carer. We hope this work continues. We also support the
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priority aim to work with commissioners to look at the availability of memory clinics for
patients when dementia is diagnosed.
We look forward to see the continued development of the ‘Achieving Excellence’
programme aimed at transforming the patient experience and working with the Trust in
the future to support the drive for quality improvement.
Sarah Wren MBE, Chairman Healthwatch Hertfordshire, June 2013
Healthwatch Essex response to Princess Alexandra Hospital NHS Trust (PAH)
Quality Accounts
We recognise that Quality Account reports are a useful tool in ensuring that NHS healthcare
providers are accountable to patients and the public about the quality of service they provide. We
fully support these reports as a means for providers to review their services in an open and honest
manner, acknowledging where services are working well and where there is room for improvement.
We welcome the opportunity to provide a patient and public perspective on the Quality Accounts.
As a newly-established organisation (we took on statutory responsibility on 1st April 2013), we are
not in a position to comment retrospectively on the findings of the past year. We will, however,
cooperate fully in the future production of these reports. We are an organisation which intends to
provide comment rooted in evidence – be it ‘soft’ intelligence or more extensive, quantitative data.
Following the Francis Report, we believe there is a significant challenge and opportunity for the
whole health and social care system to look at how evidence relating to patient experience can be
set on an equal footing with standard NHS data about performance and quality.
We share the aspiration of making the NHS more patient-focussed and placing the patient’s
experience at the heart of health and social care. An essential part of this is making sure the
collective voice of the people of Essex is heard and given due regard, particularly when decisions are
being made about quality of care and changes to service delivery and provision.
Our wish is therefore that Healthwatch Essex works with its partners in the health and social care
sector to engage patients and service users effectively and to ensure that their views are listened to
and acted upon.
We look forward to working together in the production of Quality Accounts in the coming year and
making sure that the voice and experience of patients and the public form an integral part of these
documents. At a time when the NHS is facing great change and financial challenge, patient
experience and quality of care are more important than ever, and we welcome the opportunity to
help shape the NHS of the 21st century.
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CASE STUDY
Achieving Excellence
Under the banner of Achieving Excellence, the Patient Experience Improvement
Programme for The Princess Alexandra Hospital NHS Trust has initiated several
work programmes which will enable the rapid transformation in our patient
experience that we all seek. We can only achieve that by opening up the
organisation to feedback. To move from a one way conversation where we are
always the experts, to one where patients feel valued and work as equal partners.
To do that we will need your help and so you can write to us with your views, or you
may wish to join our new Patient Panel. In any case, you can write to us at:
The Patient Experience Team
FREEPOST RTCS-ZHRB-RSGL
Hamstel Road
Harlow, Essex CM20 1QX
Or call us on 01279 82 70 84 Monday to Friday between 9am and 5pm.
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