Quality Account 2012/13
Quality Account 2012/13
Quality Account 2012/13
Contents
What is a Quality Account?
02
Part 1
Statement on Quality from the Chief Executive
06
Part 2
Performance against priorities for Quality Improvement 2012/13
10
Priorities for the coming year for the Hospital
Priority 1 – Reduce the incidence of Healthcare Associated Infections
Priority 2 – Reduction in the rate of incidents resulting in severe harm or death
Priority 3 – Reduction in VTE/clots
Priority 4 – Reduction in community acquired pressure ulcers
Priority 5 – Increase in the number of patients who die in their preferred place – community
Priority 6 – Increase in the number of patients who are offered a Holistic Needs Assessment
Priority 7 – Reduction in number of emergency readmissions within 28 days
Priority 8 – Improvement in patient experience and chemotherapy waiting times
Priority 9 – Responding to inpatient’s personal needs
Priority 10 – Staff recommending The Royal Marsden to friends and family
Priority 11 – The percentage of new birth visits up to day 14 (Health Visitors)
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Part 3
Outline of Quality Improvements in 2013/14
The quality priorities for 2013/14
The quality objectives and priorities of the Trust for the last three years
Statements of assurance from the Board
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47
Part 4
Review of quality performance (previous year’s performance)
56
Appendices
Appendix 1 – Quality Indicators where national data is available from the Health and
Social Care Information Centre (HSCIC)
Appendix 2 – Statements from key stakeholders
Appendix 3 – Statement of Director’s responsibilities in respect of the Quality Account
Appendix 4 – Independent Auditor’s Assurance Report
Appendix 5 – Glossary of terms
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1
The Royal Marsden NHS Foundation Trust
Quality Account 2012/13
Quality Account
Firstly, we have detailed how we performed in 2012/13 against the priorities and objectives we set
ourselves under the following categories:
What is a Quality Account?
Safe care
All NHS hospitals or trusts have to publish their annual financial accounts. Since 2009 as part of
the movement across the NHS to be open and transparent about the quality of services provided
to the public, all NHS hospitals must publish a Quality Account. The public and patients can also
view quality across NHS organisations by viewing the Quality Accounts on the NHS Choices
website: www.nhs.uk
The dual functions of a Quality Account are to:
1. Summarise performance and improvements against the quality priorities and objectives we
set ourselves for 2012/13
2. Outline the quality priorities and objectives we set ourselves going forward for 2013/14.
Review of 12/13
Quality Information
Look Back
Set out priorities
Quality Improvement 13/14
Look Forward
Effective care
Patient experience
Where we have not met the priorities and objectives that we set ourselves, we have explained why, and
outlined the plans we have put in place to ensure improvements are made in the future.
Secondly, we have outlined our quality priorities and objectives for 2013/14 under the same categories.
We have detailed how we decided upon the priorities and objectives we have set ourselves, and how we
will achieve and measure our performance. The regulated Statements of Assurance are also included in
this part of the report.
The Quality Account is an important document for the Board, which is accountable for the quality of
the service provided by the Trust and can be used in the scrutiny and leadership of the Trust. Frontline
staff can use the Quality Account compare or benchmark their care with other Trusts or, if comparable
information doesn’t exist, with their own performance over time, to help improve their service.
For patients, carers and the public the Quality Account should be a document that is easy to read and
understand, and highlights key areas of safety and effective care delivered in a caring and empathetic
way. It should also show how a Trust is concentrating on continuously improving its care. As the public
get used to reading the Quality Account it may also help patients with choice. It is important to remember
that some parts of the Quality Account are compulsory and can be difficult to read – they are about
important areas such as the time it has taken to get from an appointment with a GP to first receiving
treatment – generally they are presented as numbers in a table at the end of this Quality Account. If there
are any areas of the Quality Account that are difficult to read or understand or you would like any help
with the content, please contact us via our Patient Advice and Liaison Service (PALS) on 0800 783 7176
or online at www.royalmarsden.nhs.uk
The Quality Account is divided into four sections:
Part 1
A statement on quality from the Chief Executive (CE)
Part 2
Performance against priorities for quality improvement 2012/13 and statements of assurance
Part 3
Outline of quality priorities 2013/14 and an explanation of who the Trust has involved in
determining the priorities including statements from key stakeholders such as Healthwatch
(replacing Local Involvement Networks), Health and Wellbeing Boards and the Commissioners
of Services. It is important to note that with the new architecture of the NHS The Royal Marsden
will work more closely in 2013/14 with the two Clinical Commissioning Groups in Sutton
and Merton to ensure that going forward the Quality Account reflects their needs
Part 4
Review of quality performance
2
3
The Royal Marsden NHS Foundation Trust
4
Quality Account 2012/13
5
The Royal Marsden NHS Foundation Trust
Part one
Introduction to The Royal Marsden
NHS Foundation Trust and a statement
on quality by the Chief Executive
The quality of patient and family care is at the
centre of everything we do at The Royal Marsden.
The Royal Marsden NHS Foundation Trust is the
largest comprehensive cancer centre in Europe
and together with its academic partner the
Institute of Cancer Research (ICR) is responsible
for the largest research programme in cancer
in the UK.
This year has been another excellent year for
the Trust as we have continued to achieve high
ratings from our two major regulators, Monitor
and the Care Quality Commission (CQC). This
commitment to meet the challenges of delivering
quality whilst delivering efficiency cost savings
of around seven per cent a year underpins our
corporate objectives for 2012/13:
1. Improve patient safety and clinical effectiveness
2. Improve patient experience
3. Deliver excellence in teaching and research
4. Ensure financial and environmental
sustainability.
Quality Account 2012/13
Our commitment to quality improvement is
evidenced by the following achievements in
April 2012 – March 2013:
National Patient Safety Agency Annual Patient
Environment Action Team (PEAT) Assessment
The PEAT inspection rated the Trust as “excellent”
overall. The inspection, which was performed at
both sites and included external inspectors and
patients, looked at the following areas: cleanliness
of the patient environment (wards, rooms, waiting
and reception areas), infection prevention and
control, safety and security, hospital food, and the
privacy and dignity afforded to patients.
The annual staff survey
A growing body of evidence has shown a clear
correlation between a satisfied workforce and high
quality patient care. The national staff survey
identifies the extent to which staff feel motivated
and engaged with their work and willingness
of staff to recommend the Trust as a place of
work/and for patients to receive treatment. How
members of staff rate the care that their employer
organisation provides can be a meaningful
indicator of the quality of care and a helpful
measure of improvement over time. The Trust
has traditionally performed very well with this
measure. The 2012/13 staff survey results showed
that 87% (421/488) of our staff who responded to
the NHS survey agreed or strongly agreed that if a
friend or relative needed treatment, they would be
happy with the standard of care provided by the
Trust. This is an increase on 2011/12, when survey
results were 84% (408/485). The national average
for this measure is 63%.
Customer Service Excellence Standard
The Customer Service Excellence (CSE)
standard replaced the Charter Mark in 2008
and is a standard achieved by public services
that are “efficient, effective, excellent, equitable
and empowering – with the citizen always
and everywhere at the heart of public services
provision” (CSE 2008).
The CSE tests, in-depth, those areas that research
has indicated are a priority for customers,
with particular focus on delivery, timeliness,
information, professionalism and staff attitude.
Emphasis is also placed on developing customer
insight, understanding the user’s experience and
robust (reliable) measures of service satisfaction.
6
The Royal Marsden was the first hospital to
be awarded the Customer Service Excellence
standard, in 2008. To maintain the award the
Trust needs to be assessed regularly and received
its last assessment on 14 December 2012. The
Trust was found to be compliant and therefore
retained the award.
Same-sex accommodation
Since April 2011 we have been able to declare
compliance and have met all the standards set by
the Government to provide accommodation for
patients that is not shared with the opposite sex.
A modern healthcare environment
Finally, 2012 has seen the completion of
several phases of a substantial capital building
programme which is ensuring that patients
and their families experience care in the most
appropriate, modern and technically sophisticated
environment.
In autumn 2012 the Centre for Molecular Pathology
opened at Sutton. This is the first centre for
molecular biology dedicated to cancer in the NHS.
This is a very exciting development as it will
bring together scientists and doctors in the same
environment, working together to develop new
medicines and treatments that will be targeted to
the unique genetic codes of each individual. These
new targeted medicines and treatments will ensure
that cancer patients all over the world benefit more
rapidly from accurate cancer treatments.
This is the fourth year that we have published
a Quality Account and we are very grateful for
the feedback we received on last year’s Quality
Account from patients, carers, the public through
Healthwatch (from 1 April 2013 Healthwatch
replaced the Local Involvement Networks), Health
and Wellbeing Boards and our commissioners
and governors. As you will see from this Quality
Account, 2012/13 has been another busy year
for The Royal Marsden NHS Foundation Trust.
The Trust has continued to improve its services
for patients and families, achieving key targets
despite the economic challenges to the NHS. We
are also committed to doing everything we can
to improve the environment and care further in
2013/14. I would like to thank all patients, carers,
staff, LINks, HWB, governors and commissioners
who have contributed to this Quality Account
for 2012/13.
I can confirm on behalf of the Board of
The Royal Marsden NHS Foundation Trust that
to the best of my knowledge, the information
presented in this Quality Account is accurate and
fairly represents the range of services we provide.
Cally Palmer CBE
Chief Executive
19 June 2013
Integrated Care
During 2012/13 the Trust has been very involved
in the leadership and shaping of one of the two
new integrated cancer systems across London:
The London Cancer Alliance (LCA). The aim of
the LCA is to improve cancer outcomes, safety of
care and the experience of care across two thirds
of London (4.8 million people). The Royal Marsden
has led and hosted the LCA this year.
This is also the second year of our integration
with Sutton and Merton Community Services.
Work continues on improving patient pathways,
ensuring that people with long term conditions
have improvements in their care and an improved
patient experience. We have also focused on
ensuring that our partnerships with the multiagency safeguarding hubs in both Sutton and
Merton are robust and effective in ensuring
that children are afforded the best joined up
care between health, social care and many
other agencies.
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The Royal Marsden NHS Foundation Trust
8
Quality Account 2012/13
9
The Royal Marsden NHS Foundation Trust
Quality Account 2012/13
Part two
Patient experience
Performance against priorities for quality improvement 2012/13 and statements for assurance
Introduction
The table below summarises the specific priorities and targets we set ourselves for Safe care, Effective
care and Patient experience for 2012/13 in the hospital.
Safe care
Priority 1
Priority 2
Priority 3
*Reduction in Healthcare
Associated Infections
(MRSA bacteraemia and
Clostridium difficile infections)
*Rate of patient safety incidents
and percentage resulting in
severe harm or death (in
2011/12 the number of deaths
from serious incidents per 100
admissions was 0.013; the
number of severe harms from
incidents per 100 admissions
was 0.021)
*Percentage of admitted
patients risk assessed for
Venous thromboembolism
Reduction in the rate of patient
safety incidents per 100
admissions and the proportion
that have resulted in severe
harm or death
95% of patients to have a
completed VTE risk assessment
Less than one
MRSA bacteraemia
Less than 16
C. difficile infections
(Report in Quality Account the
number of C. difficile infections
per 100,000 bed days)
Priority 8
Priority 9
Priority 10
Reduction in chemotherapy
waiting times and improvement
in patient experience related to
waiting times
*Ensure that we are responding
to in-patients’ personal needs
*Percentage of staff who would
recommend The Royal Marsden
to friends or family needing care
Reduction in chemotherapy
waiting times at Sutton and
Chelsea and improvement in
the patient experience related
to waiting times
Improvement in responses to
five questions (from the CQC
national survey) as monitored
through the Inpatient Frequent
Feedback Surveys
To maintain or increase the
staff survey result to this
specific question in the survey
Safe care for children
Priority 11
Percentage of babies who receive the new birth visit up to day 14
90% to be achieved
* mandatory priority
Effective care
10
Priority 4
Priority 5
Priority 6
Priority 7
Reduction in
community acquired
grade 3 and 4
pressure ulcers
Increase the number
of patients that die
in their preferred
place of death (The
National Primary Care
Snapshot Audit in End
of Life Care (2009)
found that the number
of patients achieving
their preferred place of
death is 42%)
Increase the numbers
of patients who
have been offered
an Holistic Needs
Assessment
*Avoidance
of emergency
re-admissions to
hospital within
28 days of discharge
Reduce the incidence
of severe community
acquired pressure
ulcers (grade 3 and 4)
Achieve more than
42% of patients dying
in their preferred place
of death
Increase in the
proportion of
designated patients
who will be offered
a Holistic Needs
Assessment by the end
of 2012/13
Reduction in the
number of avoidable
re-admissions to
hospital within
28 days of discharge
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The Royal Marsden NHS Foundation Trust
Quality Account 2012/13
Priority 1
–– Air testing and review of water test results where required during commissioning of new builds
Reduce the incidence of Healthcare Associated Infections (HCAIs)
–– Filtration of the air supply and careful monitoring (and filtration where necessary) of the water supply
to the wards where severely immuno-compromised bone marrow transplant patients are cared for.
Target
How did we perform in 2012/13?
To reduce the number of Clostridium difficile Infections (CDI) to 16 in 2012/13 or less and maintain
a very low incidence of Meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia.
Patients with cancer are more vulnerable to infection and if an infection is sustained, they are more
likely to develop serious complications from it. We therefore see reducing the incidence of HCAIs as an
essential safety and quality priority. This priority was selected in 2009/10 and remained an important
priority in 2012/13.
What did we do in 2012/13?
Table 1 below shows the numbers of two important health care associated infections (HCAIs): meticillin
resistant Staphylococcus aureus bacteraemia (MRSAb) and Clostridium difficile (CDI) over recent
years. These infections are monitored nationally through the Health Protection Agency (HPA) with all
hospitals submitting their information to the HPA website monthly. On 1 April 2013 HPA became Public
Health England.
Table 1: Number of cases of infections that are attributable to The Royal Marsden
Infection
Number
attributable
2009/10
Number
attributable
2010/11
Number
attributable
2011/12
Number
attributable
2012/13
Royal
Marsden
annual
objective
2012/13
MRSA
bacteraemia
1
2
1
0
≤1
C. difficile
39
34
18
15
≤16
–– We have maintained a high proportion of single rooms, making it easier to isolate infected patients
earlier. Almost half the patient accommodation on each site is in single rooms
–– Weekly audits against the criteria of the Care Quality Commission Hygiene Code continue across
almost all clinical areas of the Trust, including diagnostic and outpatient areas. These are carried out
by Sisters/Charge Nurses, Clinical Nurse Specialists, senior Allied Health Professionals and Matrons.
These visits serve multiple purposes, allowing senior professionals to view good practice that they can
take back to their own areas as well as providing an independent check on cleanliness, practice and
staff knowledge
–– Synbiotix (live web-based database) is available for all staff to view via the Trust intranet, showing the
results of Hygiene Code visits, hand hygiene and other audits, and daily checks and clinical indicators.
Performance is closely monitored and highlighted by regular emails from the Infection Prevention and
Control Team. Synbiotix also shows the results of equivalent audits of community services
–– Hydrogen peroxide vapour (HPV) decontamination of patient rooms where the occupant has had an
infection that may pose a risk to the next person to use the room is available across both hospitals.
Priority is given to rooms that have been occupied by patients with symptomatic Clostridium difficile
infection because this is the most effective way to destroy Clostridium difficile spores and minimise
the risk to other patients
–– Infection prevention and control is included in the induction programme and there is update training,
which is mandatory for all new and existing staff
–– Each ward and unit has clinical link nurses for infection prevention and control acting as clinical
champions and the Infection Prevention and Control Team hold monthly meetings for all ‘link’ staff. These
meetings include an educational session and allow staff to discuss infection prevention and control issues
–– The Royal Marsden Infection Prevention and Control Team hosted a national study day in July 2012 on
combating HCAIs, including sessions on antimicrobial resistance, water safety and the importance of
the environment in infection prevention. Almost 100 delegates from across the South East attended and
feedback on the event was very positive
–– All Trust Infection Prevention and Control policies are reviewed annually
–– Mattress audit and evaluation has been undertaken and any faulty mattresses replaced to assist in
the prevention of infection
–– Disinfectant and sporicidal wipes have been standardised across the Trust for cleaning equipment,
especially commodes
–– Advance weekly notification is provided to all wards before admission of patients previously identified
as infected or colonised with MRSA or another organism of concern, and of patients with no recorded
MRSA screen within the previous month. Outpatient departments and medical day units are notified
of patients with appointments who have previously been identified with MRSA, Clostridium difficile or
respiratory infections and provided with recommendations for management
12
The graph below shows the number of Clostridium difficile infections from April 2012 to March 2013.
Trust objective
Trust cumulative total
Sutton cumulative total
Trust month total
Chelsea cumulative total
18
16
14
12
10
8
6
4
3
2
0
April
2012
May
2012
June
2012
July
2012
Aug
2012
Sept
2012
Oct
2012
Nov
2012
Dec
2012
Jan
2013
Feb
2013
March
2013
13
The Royal Marsden NHS Foundation Trust
We have worked exceptionally hard to achieve the set objective of less than 16 cases of Clostridium
difficile infection in 2012/13, and had no cases of MRSA bacteraemia throughout the year; the target for
MRSA bacteraemia was less than or equal to one case, which was a very challenging target to achieve.
The Trust continues to commit to reducing the incidence of HCAIs still further in 2013/14.
What actions are we planning to improve our performance?
For Clostridium difficile we aim to reduce our target from 16 to 11 for 2013/14 and reduce the number
of infections by antibiotic resistant organisms, including MRSA but particularly multi-resistant gram
negative organisms.
We will aim to achieve the following:
1. Ensure that infection prevention is taken into account in all refurbishments, new builds, service
developments and other capital projects across the Trust
2. Consolidate and expand the programme of inspections and audits, including Hygiene Code
inspections; hand hygiene, Saving Lives and Essential Steps audits; local daily checks and clinical
indicators across the Trust, including Sutton and Merton Community Services
3. Facilitate access to the Synbiotix system and database for all staff across the Trust, including
Sutton and Merton Community Services, for the recording and transparent display of all the above
performance indicators
Quality Account 2012/13
Priority 2
To reduce the rate of patient safety incidents that have resulted in severe harm or death
Target
Reduction in the rate of patient safety incidents per 100 admissions and the proportion that have
resulted in severe harm or death.
In 2011/12 the number of deaths from serious incidents per 100 admissions was 0.013; the number
of severe harms from incidents was 0.021.
What did we do in 2012/13?
–– We strengthened the use of the World Health Organisation (WHO) Surgical Safety Checklist
to promote the safety of patients in the pre, peri and post operative period
–– We invested in new digital assisted defibrillators throughout the Trust to be used in the event
of cardiac arrest
–– We strengthened the use of the national venous thromboembolism prevention and treatment
algorithims across the Trust
4. Review the arrangements for the deployment and operation of the hydrogen peroxide vapour (HPV)
environmental decontamination equipment to ensure that it is used as effectively as possible and
that priority is given to those areas where it will be most beneficial, particularly rooms that have been
occupied by symptomatic patients with Clostridium difficile infection
–– We continued to work on preventing medication errors and falls.
5. Review teaching for all clinical staff (doctors, nurses and rehabilitation therapists) on the importance
of optimal infection prevention and control practices to ensure that it is fit for purpose, provides staff
with the information, knowledge and skills necessary to minimise the risk of infection and meets the
requirements of the Hygiene Code
This year is the first time that this indicator has been required to be included within the Quality Report
alongside comparative data provided, where possible, from the Health and Social Care Information Centre.
The National Reporting and Learning Service (NRLS) was established in 2003. The system enables patient
safety incident reports to be submitted to a national database on a voluntary basis designed to promote
learning. It is mandatory for NHS trusts in England to report all serious patient safety incidents to the Care
Quality Commission as part of the Care Quality Commission registration process.
6. Host a third study day in 2013 at The Royal Marsden on combating HCAIs, with the particular
emphasis on the growing threat of multi-drug resistant gram negative organisms
7. Provide a proactive and responsive infection prevention service to all areas of the Trust, with
particular emphasis on increasing awareness of the service in community staff
8. Review the costs and benefits of pre-surgical decolonisation for all patients to reduce the risk of post
operative wound infection with a view to introducing universal preoperative decolonisation
9. Undertake a detailed retrospective analysis of the antibiotic profiles on those patients who acquired
Clostridium difficile in hospital to see if there are ways in which we need to revise our antibiotic usage.
How will improvement be measured and monitored?
Improvements will be monitored by the monthly Infection Prevention and Control Team meeting. This
is a multidisciplinary meeting chaired by the Chief Nurse, who is the Director of Infection Prevention
and Control for the Trust. Bacteraemia caused by both meticillin-resistant and meticillin-sensitive
Staphylococcus aureus (MRSA and MSSA), vancomycin-resistant enterococci (VRE) and Escherichia coli
will be reported externally to the new Public Health England, as will all confirmed Clostridium difficile
infections. Numbers of selected infections will be monitored internally to the Board in the Trust Board
Scorecard and published in the quarterly Integrated Governance Reports. Reduction in HCAIs remains
a priority for 2013/14 to prevent further harm to patients.
How did we perform in 2012/13?
Patient safety incidents resulting in severe harm or death
The Trust reports all patient safety incidents reported on Datix to the NRLS. Prior to NRLS producing their
six monthly reports, the Trust re-submits all patient safety incidents which captures changes made as a
result of investigations. The NRLS does not update its previously reported figures so these changes may not
be reported by the NRLS and the data held by the Trust may not be the same as that reported by the NRLS.
Rate of reported patient safety incidents (Severe harm or Death), per 100 admissions – 0.008
Number of patient safety incidents (Severe harm or Death) – 4
Total patient safety incidents – 2978
Patient safety incidents (Severe harm or Death) as % of all patient safety incidents – 0.13%
What actions are we planning to improve our performance?
–– To increase the use of the Team Simulation for Emergency situations to other clinical teams
–– Introduce the use of the new National Early Warning System which will be audited throughout 2013/14
–– Investigate the use of VitalPac systems to ensure clinical teams intervene early when patients deteriorate.
How will improvements be measured and monitored?
–– Through the specialist Morbidity and Mortality meetings
–– Clinical Audit
–– National mandatory audits
–– Utstein cardiac arrest audit.
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The Royal Marsden NHS Foundation Trust
Q1
Q2
Q3
Q4
Quarter target
95%
95%
95%
95%
Prophylaxis prescribed
96%
96%
96%
96%
The graph below demonstrates the percentage of patients who had a risk assessment completed.
VTE risk assessment compliance April 2011 to March 2013
What did we do in 2012/13?
Level of assessment achieved
The multidisciplinary VTE Steering Board is now well established and VTE risk assessment for all
appropriate patients is embedded into clinical practice in the hospital. All elective inpatients are sent
information leaflets in advance of their admission to inform them of what they can do to help prevent
clot formation. Furthermore, posters and patient information leaflets are available in the clinical areas
or from Patient Advice and Liaison Service (PALS).
16
March 2013
Feb 2013
Jan 2013
Dec 2012
Nov 2012
Oct 2012
Sept 2012
Aug 2012
July 2012
June 2012
May 2012
April 2012
March 2012
Feb 2012
80
April 2011
–– Updating of the VTE Patient Information booklet in line with NICE guidance published in June 2012.
85
Jan 2012
–– The day units are developing alert cards for patients and providing stockings for patients who may
have a reduction in energy levels. The alert cards instruct patients to apply the stockings if their
activity levels reduce when on their chemotherapy
Dec 2011
–– Implementation of the new prescription drug chart which incorporates VTE risk assessment and
24 hour reassessment. The drug chart also contains information on prescribing for the junior doctors
90
Nov 2011
–– Performance manage the compliance with risk assessment; detailed performance reports are sent
out to appropriate staff daily. Appropriate prophylaxis prescriptions are monitored monthly
95
Oct 2011
–– Ensure that every confirmed diagnosis of a VTE undergoes a root cause analysis to determine the
underlying cause of the VTE and if any other preventative action could be taken. The consultant in
charge of the patient is contacted if there are any concerns about care
100
Percentage of patients assessed
More specifically the steering group has directed the following actions:
Trust target
Sept 2011
VTE is a collective term for deep venous thrombosis and pulmonary embolism. A deep vein thrombosis
is a blood clot that forms in a deep vein (usually in the leg) and sometimes a clot breaks off and travels
to the arteries of the lung where it will cause a pulmonary embolism. VTE can be avoided by giving
preventative treatment (prophylaxis) to patients at risk. Patients with cancer are at greater risk of
developing VTE therefore this continues to be a safety priority for us.
VTE
Aug 2011
All appropriate patients will have venous thromboembolism (VTE) assessment within 24 hours of
admission and receive prophylaxis; to undertake a root cause analysis on all confirmed VTE.
July 2011
Target
We have achieved the NHS Commissioning for Quality and Innovation (CQUIN) target of 95%
compliance for ensuring all of our patients are appropriately assessed for risk of VTE in 2012/13.
Furthermore we have reached the 95% level of appropriate prophylaxis being prescribed to prevent VTE.
June 2011
Reduction in venous thromboembolism (VTE) events/clot formation
How did we perform in 2012/13?
May 2011
Priority 3
Quality Account 2012/13
17
The Royal Marsden NHS Foundation Trust
Quality Account 2012/13
What actions are we planning to improve our performance?
Priority 4
–– Regular audit of a new prescription drug chart, checking documentation of patient weights and
feeding back to Ward Sisters, Matrons and Pharmacy
Reduction of pressure ulcers
–– Daily score cards will be sent to VTE leads to check on progress
Target
–– Monthly compliance checking of appropriate mechanical prophylaxis
–– Weekly compliance checking VTE reassessment within 24 hours
–– All hospital acquired thrombosis will be reviewed by consultants who will check for recurring themes
–– Emphasis will be placed on weight appropriate prescribing to ensure we are compliant with the
CQUIN targets
–– Two random cases of hospital acquired thrombosis will be audited monthly, checking for appropriate
treatment dose
–– Monthly VTE Steering Group meetings have been scheduled
–– VTE reporting will take place regularly to the Junior Doctors Forum
–– VTE presentation at each Junior Doctors Induction
–– Ongoing audit of patient information and support received in the Outpatient departments
–– Developing alert cards and anti-thrombolic stockings for patients in day care.
How will improvement be measured and monitored?
VTE incidents and performance with assessment and prevention procedures will be monitored by the
VTE Steering Board. Performance will also be monitored at the Key Performance/CQUIN Steering
Board and through the monthly Board scorecard. The Trust has achieved its targets, however this will
continue to be included as a priority for 2013/14 because “Quality Accounts: reporting arrangements for
2012/13” (DoH, January 2013) and the “NHS Outcomes Framework 2012/13” suggest this remains an
important indicator of improvement in protecting patients from avoidable harm. In 2013/14 the actions
described above will be ongoing and embedded into practice. This will be demonstrated by ongoing
monitoring and audit of compliance.
To reduce the incidence of severe community acquired category 3 and 4 avoidable pressure ulcers.
Pressure ulcers are a good indicator of quality of care; their prevention requires assessment and good
skin care and adequate hydration and nutrition. Some patients with long term conditions are at high
risk of developing pressure ulcers because they have fragile skin, can have reduced nutrition and some
medications can increase the risk. A rising incidence of pressure ulcers across many patients can be
an early indication of deteriorating standards and therefore must be monitored closely. During 2012/13
guidance was made available from NHS London on pressure ulcers in relation to being avoidable or
unavoidable and all factors must be taken into account when deciphering the cause of the pressure ulcer.
What did we do in 2012/13?
Since 2011 all serious pressure ulcers (category 3 and 4) have been reported as serious incidents
nationally. All pressure ulcers in the hospital and the community are reported on Datix our online
incident reporting system and all serious pressure ulcers are investigated using root cause analysis.
Monthly category 3 and 4 pressure ulcer incident panel meetings are chaired by the Assistant Chief
Nurse (Operations). These are multidisciplinary team meetings with representation from both community
and hospital teams. These meetings have created great learning opportunities and a venue for sharing
best practice. There is also a pressure ulcer working group, chaired by the Clinical Nurse Director for
Adult Community Services which is tasked to take forward the recommendations of the incident panel
meetings and this is overseen by the Pressure Ulcer Strategy Group chaired by the Assistant Chief
Nurse (Operations).
More specifically the pressure ulcer group has directed the following actions:
–– Updating the pressure ulcer risk assessment and prevention policy to include hospital and
community settings
–– Mapped the pressure ulcer pathway
–– Introducing systems to ensure holistic assessment of patients occurs at the outset of care and
that good practice is shared amongst all
–– Developed patient and carer information leaflets on pressure ulcer prevention and care
–– Completed a knowledge and skills gap analysis and developed appropriate learning and
development days
–– Ensuring that pressure ulcer prevention and management is part of mandatory training
–– Ensuring that all staff are familiar with appropriate documentation for assessing and monitoring
pressure areas as well as treating pressure ulcers.
From October 2010, all category 3 and 4 pressure ulcers have been classified as a Serious Incident (SI)
and have been reported to the Clinical Quality and Review Group and the Integrated Governance and
Risk Management committee. This process has been hugely beneficial within community services so
that we can easily establish the root cause to why a pressure ulcer developed and determine whether
the pressure ulcer was avoidable or unavoidable.
Investigation panels attended by representatives from the relevant district nurse teams have been held
for each of these incidents to give clinical oversight and to ensure that sufficient organisational learning
takes place.
18
19
The Royal Marsden NHS Foundation Trust
Quality Account 2012/13
How did we perform in 2012/13?
What actions are we planning to improve our performance?
There are a larger number of pressure ulcers in the community. Pressure damage in the community
is more challenging to prevent because the environment is much harder to control: many people are
looked after in the community by formal and informal carers that the Trust has no responsibility for,
many patients are frail/elderly and the home environment is less easy to control. The Trust is however
committed to reducing pressure ulcers in the community setting. The table below shows the number
of community acquired category 3 and 4 pressure ulcers.
A large programme of work has been commenced by community services to address pressure ulcer
prevention strategies. All category 3 and 4 incidents are investigated and presented at a panel to identify
root causes and to learn from incidents to improve care for patients. From this the following pieces of
work have started:
2012/13
Number of community acquired pressure ulcers
Category 3
39
Category 4
7
–– Training and education for local authority staff (formal carers) has been set up and delivered
–– A programme has been delivered to care homes as part of a CQUIN target for staff on pressure ulcer
prevention, nutrition, continence, falls and diabetes. The training was well evaluated
–– Re-design and re-launch of leaflets for patients and both paid and unpaid carers on skin care and
prevention strategies. These are routinely given to patients on admission to the service
The chart below outlines the number of pressure ulcers (category 3-4) that were acquired within the
community setting during the period April 2011 to March 2013.
–– Work commenced on joint care planning with local authority staff that provide care to patients known
to the District Nursing teams
Community acquired category 3 and 4 pressure ulcers April 2011 to March 2013
Category 3
–– Investment in workforce to assist Tissue Viability Nurses to support District Nursing teams in pressure
ulcer prevention and management strategies including the development of registers of patients at risk
of pressure ulcer development
Category 4
8
–– A CQUIN this year has also focussed on pressure ulcer prevention and management with investment
for an extra Tissue Viability Nurse to support the project
7
–– Developing care plans and pathways
6
Number of pressure ulcers
–– Training programmes for internal staff are now mandatory on pressure ulcer prevention and
management. A skills gap workshop for registered nurses has been undertaken to identify areas
where we need to invest more training
–– Equipment update training days have taken place and continue
5
–– The Pressure Ulcer Prevention and Management policy has been reviewed and updated to reflect
any changes in documentation and processes
4
–– Audits of pressure ulcer returns to enforce prevention strategies
–– Developing and rolling out checklist to ensure all assessments completed in a timely manner
3
–– To review wound photography guidelines to ensure they are fit for purpose
–– Adults at risk policy revised to incorporate pressure ulcer management
2
–– Shared learning for teams
20
March 2013
Feb 2013
Jan 2013
Dec 2012
Nov 2012
Oct 2012
Sept 2012
Aug 2012
July 2012
June 2012
May 2012
April 2012
March 2012
Feb 2012
Jan 2012
Dec 2011
Nov 2011
Oct 2011
Sept 2011
Aug 2011
July 2011
How will improvement be measured and monitored?
June 2011
0
May 2011
–– The pressure ulcer panel continues monthly and clarity gained on whether the pressure ulcer
was avoidable or unavoidable.
April 2011
1
Pressure ulcers will continue to be monitored by the Pressure Ulcer Working Group which is chaired by
the Clinical Nurse Director for Adult Community Services, with serious pressure ulcers being reported
in the monthly Quality Account presented to the Board. All category 3 and 4 pressure ulcers will be
overseen by the Trust Integrated Governance and Risk Management Committee. Reducing pressure
ulcers in the community setting will remain a quality priority for 2013/14; hospital acquired pressure
ulcers will continue to be tracked as described but will not form part of the 2013/14 quality account.
The actions described above will continue through 2013/14 to ensure we reduce the number of avoidable
community acquired pressure ulcers.
21
The Royal Marsden NHS Foundation Trust
Priority 5
To increase the proportion of patients that die in their preferred place of death.
Target
To achieve more than 42% of patients dying in their preferred place of death.
To increase the numbers of patients dying in their preferred place of death where previously indicated
and recorded on Coordinate my Care (CMC) to over 42% as reported in The National Primary Care
Snapshot Audit in End of Life Care (2009). Coordinate my Care is a communication clinical service that
coordinates of end of life care for patients who receive multiple services and care from multiple providers,
allowing patients to have choice and improved quality of end of life care. There is a central database in
London that is hosted by The Royal Marsden.
What did we do in 2012/13?
–– 17/26 (65.4%) patients known to The Royal Marsden who were entered onto Coordinate my Care
by staff of The Royal Marsden NHS Foundation Trust achieved their preferred place of death
–– 20/26 (76.9%) patients known to The Royal Marsden who were entered onto Coordinate my Care
by staff of The Royal Marsden achieved their preferred place of death or died at home.
How did we perform in 2012/13?
–– Of the nine patients who didn’t achieve their documented preferred place of death:
–– three died at home
–– three died in a hospice
–– two died in hospital, one due to no bed being available in the hospice
Quality Account 2012/13
What actions are we planning to improve our performance?
–– Education
–– Palliative care teaching on biannual Royal Marsden hosted south west/north west Core Medical
Training regional teaching to include emphasis on end of life care planning
–– Palliative care in-house study days to include advance care planning
–– Nursing education on identifying progression of the dying phase
–– Close working between palliative care and oncology teams
–– Involvement of Hospital2Home team when patients are being officially discharged from hospital with
no further follow up appointments scheduled
–– Use of the weekly Palliative Care multidisciplinary team meeting to ensure that preferred place of care
and death is being addressed for patients known to the Palliative Care Team
–– Roll out of Coordinate my Care across London with associated education programme which will:
–– Highlight the importance of addressing preferences for end of life care
–– Improve documentation between different healthcare providers to ensure smooth transfer of accurate,
up to date information on end of life care preferences.
How will improvement be measured and monitored?
–– Weekly review of outcomes for preferred place of care and death for patients referred to the
Hospital2Home service
–– Weekly reporting on ‘preferred place of death’ from the Coordinate my Care team. This information
is then disseminated to lead clinician and lead end of life commissioner within each Clinical
Commissioning Group.
–– one had stated ‘other’ as ‘preferred place of death’ with no further documentation to identify
where that might be.
22
23
The Royal Marsden NHS Foundation Trust
Priority 6
To increase the number of patients who are offered an Holistic Needs Assessment
Quality Account 2012/13
The table below shows which units and how many patients were offered a Holistic Needs Assessment to
complete and how many chose to return the form.
Unit
HNA offered
HNA returned
Breast
322
86
Gastrointestinal
69
58
Gynaecology
26
13
Head and Neck
50
11
Lymphoma
28
3
Late Effects
407
174
What did we do in 2012/13?
Lung
86
3
–– The Nurse Consultant for Living With and Beyond Cancer undertook a service evaluation to identify
the number of Clinical Nurse Specialists offering Holistic Needs Assessments to patients, and to
identify a consistent framework for Holistic Needs Assessment
Melanoma
21
1
Palliative Care
14*
3
–– In July 2012 the London Cancer Alliance Interim Clinical Board agreed that a Holistic Needs
Assessment must be offered within two weeks of a cancer diagnosis and offered again when primary
treatment has been completed, whether the treatment is surgery, radiotherapy or chemotherapy
Urology
9
6
Total 2012/13
1035
358 (35%)
Target
To achieve an increase in the number of designated patients who will undergo Holistic Needs
Assessment by the end of 2012/13.
A holistic needs assessment (HNA) is a process of gathering information from the patient and/or carer
in order to inform discussion and develop a deeper understanding of what the person living with and
beyond cancer knows, understands and needs.
A Holistic Needs Assessment is not a one-off exercise, but is the basis of assessment and care planning
from diagnosis onwards.
–– The Trust has been accepted as a Macmillan e-HNA pilot site and work is underway for this bringing
the Holistic Needs Assessment to patients via electronic tablets
–– A policy around the purpose and usage of Holistic Needs Assessment is in development.
How did we perform in 2012/13?
–– By the end of the first quarter Clinical Nurse Specialists offered 249 patients the Holistic Needs
Assessment form to complete and 112 (45%) were returned
–– Within the second quarter Clinical Nurse Specialists offered 275 patients the Holistic Needs
Assessment form to complete and 103 (38%) were returned
–– Within the third quarter Clinical Nurse Specialists offered 231 patients the Holistic Needs
Assessment form to complete and 30 (13%) were returned
–– Within the fourth quarter Clinical Nurse Specialists offered 280 patients the Holistic Needs
Assessment form to complete and 113 (40%) were returned
–– Throughout the year 1035 holistic assessment needs forms were offered to patients and 358 (35%)
were returned.
* it was agreed that palliative care would not give out anymore forms as patients should be offered a Holistic Needs Assessment at the time
of diagnosis and at the end of primary treatment.
What actions are we planning to improve our performance?
–– Continue to encourage the use of the Holistic Needs Assessment across all clinical teams
–– Agreeing Holistic Needs Assessment (HNA) service plans with clinical teams and supporting
their implementation
–– Encouraging the use of approved HNA and care planning templates using the intranet
–– Providing training and support for staff in implementing HNAs
–– Present Trust wide HNA results to all MDTs
–– Improve the response rate for completion of HNA forms.
How will improvement be measured and monitored?
–– Assisting with gathering data to meet the London Cancer Alliance metric
–– Within The Royal Marsden each clinical team or service will be asked to collect their own data, either
by individual Clinical Nurse Specialist or by team. To be agreed by Divisional Clinical Nurse Directors
with input from the Nurse Consultant for Living With and Beyond Cancer
–– The numbers of completed Holistic Needs Assessments per clinical team will be monitored by the
performance team monthly
–– Overall completion rates will be presented by clinical speciality in the Quality Account quarterly.
24
25
The Royal Marsden NHS Foundation Trust
Quality Account 2012/13
Priority 7
The table below shows the number of patients that were readmitted within 28 days from April 2012
to March 2013.
Avoidance of emergency readmissions to hospital within 28 days of discharge
Target
To achieve a reduction in the number of avoidable readmissions to hospital within 28 days
of discharge.
What did we do in 2012/13?
Together with the South West London Acute Commissioning Unit we undertook an external audit
of all readmissions over a 12 month period.
The results were presented at the Clinical Quality Review Group (CQRG)
How did we perform in 2012/13?
The chart below shows the percentage of patients that were readmitted within 28 days from April 2012
to March 2013.
Reported percentage of emergency readmissions
Percentage of eligible admissions resulting in an eligible readmission
0.7
0.6
0.5
Month
Number of patients readmitted within 28 days
April 2012
11
May 2012
10
June 2012
14
July 2012
22
August 2012
14
September 2012
13
October 2012
13
November 2012
11
December 2012
8
January 2013
9
February 2013
11
March 2013
9
What actions are we planning to improve our performance?
–– Continuous review and evaluation of clinical care especially using the Enhanced Recovery
Programme (ERP)
0.4
–– Monthly prospective audit to monitor rates.
0.3
0.2
0.1
0
April
2012
26
May
2012
June
2012
July
2012
Aug
2012
Sept
2012
Oct
2012
Nov
2012
Dec
2012
Jan
2013
Feb
2013
March
2013
27
The Royal Marsden NHS Foundation Trust
Quality Account 2012/13
Priority 8
How did we perform in 2012/13?
Reduction in chemotherapy waiting times and improvement in patient experience related to
waiting times
Patients are asked to give their feedback in real time. As they leave the outpatients department
volunteers ask patients to give their responses on hand held devices to a variety of questions about their
appointment. During 2012/13 between 30 and 90 patients have responded each month.
Target
Reduction in chemotherapy waiting times at Sutton and Chelsea and improvement in the patient
experience related to waiting times.
In response to the question How do you feel about how long, from your stated appointment time you had to
wait for your treatment to start? The chart below show that across the Trust during 2012/13 on average
64% of patients waited about the right length of time for their treatment to start.
Waiting time to start of treatment
What did we do in 2012/13?
Could have been a lot sooner
Reduction of chemotherapy waiting times
90
80
70
60
Percentage
–– Introduction of a new appointment system at Chelsea site to improve treatment appointments and
reduce waiting times
About right
100
The management of chemotherapy waiting times is a particular challenge for the organisation because
of the complexity of checking it is safe to proceed to chemotherapy. Chemotherapy needs to be prepared
in an aseptic unit (where staff are gowned and gloved to prepare chemotherapy). Furthermore several
checking procedures have to be undertaken. In addition, the data below also include patients who are
on clinical trials. Some chemotherapy research studies need up to four hours preparation time once goahead for treatment has been confirmed.
The Trust is working hard at reducing the chemotherapy waiting times and improving the patient
experience by the following:
Could have been sooner
50
40
–– Planned introduction of scheduling system at Sutton from March 2013
30
–– Improvements in pre-prescribing of chemotherapy to give pharmacy time to prepare chemotherapy
in advance of the visit
20
–– Production of a new patient information leaflet to inform patients about the process of
chemotherapy production
10
28
March 2013
Feb 2013
Jan 2013
Dec 2012
Nov 2012
Oct 2012
Sept 2012
Aug 2012
July 2012
June 2012
May 2012
April 2012
March 2012
Feb 2012
Jan 2012
Dec 2011
Nov 2011
0
Oct 2011
–– Improved communication between the staff and patients to keep them informed about their wait.
29
The Royal Marsden NHS Foundation Trust
Quality Account 2012/13
In response to the question Were you told how long you would have to wait? the chart below shows that
on average 18% (140) of patients did not have to wait, 30% (241) were not told how long they would have
to wait and 44% (336) were told and the wait was shorter or about as long as they had been told. Eight
per cent (66) found that the wait was longer than they were told.
In response to the question Were you told why you would have to wait? the chart below shows that on
average 56% (371) of patients were told why they would have to wait and 29% (191) were not told but
did not mind.
Were you told why you would have to wait?
Were you told how long you would wait?
Don’t know
Not told
No, would have liked reason
Yes and wait was longer
Yes and wait was shorter
Yes and wait was as long as told
Yes
No and didn’t mind
100
No did not have to wait
90
100
80
90
70
80
Percentage
60
70
Percentage
60
50
40
50
30
40
20
30
10
20
March 2013
Feb 2013
Jan 2013
Dec 2012
Nov 2012
Oct 2012
Sept 2012
Aug 2012
July 2012
June 2012
May 2012
April 2012
March 2012
Feb 2012
Jan 2012
Dec 2011
Oct 2011
March 2013
Feb 2013
Jan 2013
Dec 2012
Nov 2012
Oct 2012
Sept 2012
Aug 2012
July 2012
June 2012
May 2012
April 2012
March 2012
Feb 2012
Jan 2012
Dec 2011
Nov 2011
Oct 2011
0
Nov 2011
0
10
What actions are we planning to improve our performance?
–– New information leaflets explaining the visit for treatment have been produced
–– Waiting time information for display on the Medical Day Unit has been implemented
–– Announcements being made every 30 minutes in the outpatients department
–– Staff are speaking with individual patients when delays to appointments occur.
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The Royal Marsden NHS Foundation Trust
Priority 9
Ensure that we are responding to inpatients’ personal needs
Target
To improve in the responses to five questions related to “Improving responsiveness to personal needs
of patients”. These five questions are taken from the national inpatient survey which is reported by the
Care Quality Commission.
Delivery of personalised medicine is one of the Trust’s strategic priorities. It is therefore important that
we understand the patient experience when they attend outpatient departments, day units and inpatient
areas. In May 2009 we started using frequent feedback hand-held devices in our day units and outpatient
areas and the matrons are responsible for developing action plans in response to recurrent concerns.
In 2012 these started being used in the inpatient areas.
What did we do in 2012/13?
The Patient Experience Feedback Group chaired by the Chief Nurse has overseen the following actions:
–– Development of the real time feedback to the inpatient areas; the questionnaire has been developed
and agreed with the Patient Feedback Steering Group and the volunteers have been trained to deliver
the questionnaire
–– Development of the real time feedback plan for the Oak Centre for Children and Young People
including Focus Groups for selected age groups
–– Commencement of new scheduling system unit to formalise the scheduling of day unit appointments
in an effort to reduce waiting times for chemotherapy.
Quality Account 2012/13
How did we perform in 2012/13?
Inpatient Survey 2012 CQUIN data
The NHS Commissioning for Quality and Innovation (CQUIN) groups together five questions from
the annual national inpatient survey that indicate how trusts perform in “Improving responsiveness to
personal needs of patients”. The following five questions are below and the table shows how the scores
have improved over the last three years.
Q32 Were you involved as much as you wanted to be in decisions about your care and treatment?
Q34 Did you find someone on the hospital staff to talk to about your worries and fears?
Q36 Were you given enough privacy when discussing your condition or treatment?
Q56 Did a member of staff tell you about medication side effects to watch for when you went home?
Q62 Did hospital staff tell you who to contact if you were worried about your condition or treatment
after you left hospital?
The Patient Experience CQUIN results for The Royal Marsden are as follows:
Year
Q32
Q34
Q36
Q56
Q62
Overall CQUIN score
2012
86.8
76
92.2
73
93
84.2
2011
83.4
75.7
91.6
70.4
92.8
82.8
2010
82.3
74.6
90
68.4
94.5
82
What actions are we planning to improve our performance?
The Trust will continue to develop the nurse handover structure to ensure that discharge planning is
discussed and agreed with the patient. Furthermore, it is proposed that patients are provided with a copy
of their discharge summary when they leave the hospital.
How will improvement be measured and monitored?
The inpatient experience will be measured by the frequent feedback survey that has commenced in the
inpatient areas and by the annual national inpatient survey. This will continue to remain important for
the Trust and will continue to be part of the Quality Account for 2012/13; the NHS Operating Framework
for 2012/13 includes an organisation’s responsiveness to patients needs as key indication of the quality of
the patient experience.
32
33
The Royal Marsden NHS Foundation Trust
Quality Account 2012/13
Priority 10
Priority 11
Monitoring of the percentage of staff who would recommend The Royal Marsden to friends
and family
Safe care for children
Target
To maintain or increase the staff survey result to this specific question in the annual national
staff survey.
The national staff survey is conducted annually. In 2011/12 the Trust survey showed that when asked
to consider the following statement If a friend of relative needed treatment, I would be happy with the
standard of care provided by this Trust 84% (408/485) of staff would recommend The Royal Marsden
to friends and family.
What did we do in 2012/13?
We continued to work with staff to improve services for patients through the year and have held focus
groups with staff to discuss ways in which services could be provided better. We shared outcomes of
patient surveys and our monitoring reports with staff.
The Trust took part in the national early implementer scheme to introduce the Prime Minister’s question
to all inpatients. The ‘friends and family’ test was in place from January 2013 in all inpatient areas. All
patients when they are discharged are asked to answer the ‘friends and family’ question and place their
response in a confidential box. The first results show that across 18 wards during the month of February
2013 of patients that were discharged 106 responded with a score of 4.9/5.0.
How did we perform in 2012/13?
Staff in this year’s survey have been asked to consider the following statement:
If a friend or relative needed treatment I would be happy with the standard of care provided by this
organisation 87% (421/488) of staff would recommend The Royal Marsden to friends and family.
This is an increase of three per cent from last year’s result.
Table 1: Numbers of staff responding to question in national staff survey
Agreed or strongly agreed
Neither agree nor disagree
Target
New Baby Review: The percentage of babies who receive the new birth visit up to day 14 after birth.
90% to be achieved.
The New Birth Visit is part of the Healthy Child Programme – the universal clinical and public health
programme for children and families from pregnancy to 19 years of age. The Healthy Child Programme,
led by health visitors and their teams, offers every child a schedule of health and development reviews,
screening tests, immunisations, health promotion guidance and support for parents tailored to their
needs, with additional support when needed and at key times. There is strong evidence supporting
delivery of all aspects of the Healthy Child Programme, which is based on Health for All Children, the
recommendations of the National Screening Committee, guidance from the National Institute of Health
and Clinical Excellence and a review of health-led parenting programmes by the University of Warwick.
This universal service visit from health visitors provides the Healthy Child Programme to ensure
a healthy start for children and family and support for parents and access to a range of community
services/resources. This child health surveillance, health promotion and parenting support elements of
the Healthy Child Programme for pregnancy and the first five years of life.
The New Baby Review is a face-to-face review by 14 days with mother and father and includes advice
and support on:
–– Infant feeding
–– Promoting sensitive parenting
–– Promoting development
–– Assessing maternal mental health
–– Sudden Infant Death support
–– Keeping safe – accident prevention advice.
Disagreed or
strongly disagreed
If parents wish or there are professional concerns:
–– An assessment of baby’s growth
2012
421 (87%)
51 (10%)
13 (3%)
–– On-going review and monitoring of the baby’s health
2011
408 (84%)
55 (11%)
19 (4%)
–– Safeguarding.
What actions are we planning to improve our performance?
–– Encourage staff feedback on how our patient services could be improved
–– Continue to promote quality monitoring reports and other information on our performance to staff
Health Visitors regard this review as a priority together with safeguarding and we are continually
reviewing how we address those families not visited within the timescale. Reasons for this include
mother and baby staying with relatives outside the area for an initial period of time and babies being
born in the area who are resident in other areas. However, there are still a number that we can aim to
visit within the timescale.
–– Continue to feedback on the ‘friends and family’ test responses to staff.
How will improvement be measured and monitored?
–– Through the annual staff survey responses.
34
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The Royal Marsden NHS Foundation Trust
Quality Account 2012/13
Table 1: Percentage of visits undertaken within 14 days after birth (those who live in the borough
of Sutton): Target 90% monthly.
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Number (percentage) of
children receiving new-birth
visit by 14 days of age
403 (91.4%)
414 (91.6%)
454 (92.7%)
470 (93.4%)
437 (91.8%)
464 (93.1%)
452 (90.1%)
417 (93.2%)
396 (91.2%)
396 (94.1%)
403 (93.5%)
372 (92.5%)
166
Number of children reaching
14 days of age in period
441
452
490
503
476
423
515
485
457
421
431
402
187
185
202
213
221
178
195
226
235
210
Sutton and Merton PCT
159 (95.8%)
178 (95.2%)
172 (93.0%)
186 (92.1%)
202 (94.8%)
200 (90.5%)
166 (93.3%)
184 (94.4%)
213 (94.2%)
221 (94%)
193 (91.9%)
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
176
Number of children reaching
14 days of age in period
163 (92.6%)
Number (percentage) of
children receiving new-birth
visit by 14 days of age
Apr-12
Sutton borough
Table 3: Percentage of visits undertaken within 14 days after birth (those who are registered with
a GP in Sutton and Merton): Target 90% monthly.
Table 2: Percentage of visits undertaken within 14 days after birth (those who live in the borough
of Merton): Target 90% monthly.
Merton borough
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Number (percentage) of
children receiving new-birth
visit by 14 days of age
217 (90.4%)
208 (92.4%)
212 (92.6%)
236 (92.2%)
236 (90.4%)
209 (92.5%)
249 (90.2%)
228 (91.9%)
214 (90.3%)
208 (94.5%)
211 (92.1%)
195 (91.5%)
Number of children reaching
14 days of age in period
240
225
229
256
261
226
276
248
217
220
229
213
36
37
The Royal Marsden NHS Foundation Trust
38
Quality Account 2012/13
39
The Royal Marsden NHS Foundation Trust
Quality Account 2012/13
Part three
–– Patient Experience Feedback group selected final quality improvement priorities
Outline of Quality Improvements in 2013/14
–– Engagement and refinement – final draft to Patient and Carer Advisory Group, Council of Governors,
Local Involvement Networks, Commissioner and the Health and Wellbeing Board; to comment and
provide a statement about the annual Quality Account.
The Department of Health and Monitor issued ‘Quality Accounts: reporting requirements for 2011/12
and planned changes for 2012/13’ in February 2012. The proposed changes followed consideration
by the National Quality Board as to how Quality Accounts should be strengthened through the
introduction of mandatory reporting against a small, core set of quality indicators. Monitor will consult
on these requirements as part of its consultation on the Annual Reporting Manual for NHS Foundation
Trusts 2012/13. From 2011/12, all acute Trusts will be required to have limited assurance work
performed on their Quality Accounts. Given the likely changes, we chose to include the proposed core
set of quality indicators proposed for requirements from 2012/13. Some of the indicators are not very
relevant to us e.g. ambulance response times, therefore these have been excluded
However, we also felt it was important to consult with our members and governors to incorporate their
views about “quality” into the Quality Account.
The process for agreeing the priorities for quality improvement were as follows:
October 2012
–– Key milestones and timetable outlined at the Patient Experience Feedback group were agreed.
Members of the Patient experience feedback group were: Sutton LINks, Sutton Health and Wellbeing
Board, Patients and Carers, Governors, Matrons from acute Trust and Community.
–– Chief Nurse to discuss and agree measurable targets alongside relevant Trust staff
March 2013 – Engagement
–– Patient Experience Feedback group finalised quality improvement priorities and targets for 2013/14
–– Chief Nurse informed Board of progress to date and obtained approval of quality improvement
priorities and targets for 2013/14
–– Draft to external stakeholders for comments and statements
–– Draft to Trust staff for comments.
April and May 2013 – Engagement and refinement
–– Progress against 2012/13 targets to be added to final draft of annual quality account
–– Copy to Marketing and Communications Department
–– To external auditors for review
–– Final copy to designer via marketing and communications team.
November 2012
May and June 2013 – Submission and publication
–– Review of first draft of the annual quality account 2012/13 priorities and progress to date
–– Reviewed at Trust’s Audit committee
–– Member’s event to discuss progress with developing and selection of quality priorities.
–– Trust’s Annual Report submitted to Monitor by 31 May 2013
December 2012
–– Trust publishes annual Quality Account on NHS Choices website and own website and submitted
copy to Department of Health by 30 June 2013.
–– Agreed on process for selecting quality priorities.
January 2013 – Review of progress
–– Review second draft of annual quality account 2012/13.
February 2013 – Engagement
–– Final draft of annual Quality Account 2012/13
–– Senior Nurse and Therapies committee reviewed priorities
–– Member’s event to discuss progress with developing and selection of quality priorities
–– Council of Governor’s meeting assisted in the selection of priorities
40
41
The Royal Marsden NHS Foundation Trust
Quality Account 2012/13
The quality priorities for 2013/14
The quality priorities and targets for 2013/14 are displayed in the table below. The priorities marked
with * were mandatory quality indicators in 2012/13 and are expected to remain mandatory for 2013/14.
There are three new (^) quality priorities for 2013/14.
Table 1: Quality priorities and targets for 2013/14
Safe care
Priority 1
Priority 2
Priority 3
*Reduction in Healthcare
Associated Infections (MRSA
bacteraemia and Clostridium
difficile infections) Applies
to Acute beds at The Royal
Marsden and patients of
Sutton and Merton Community
Services (SMCS)
*Rate of patient safety incidents
and percentage resulting
in severe harm or death (in
2012/13 the number of deaths
from serious incidents per 100
admissions was 0; the number
of severe harms from incidents
per 100 admissions was 0.012)
Applies to acute beds and SMCS
*Percentage of admitted
patients risk assessed for
Venous thromboembolism
Less than one MRSA
bacteraemia
Reduction in the rate of patient
safety incidents per 100
admissions and the proportion
that have resulted in severe
harm or death
Maintain above 95% the
number of patients who have a
completed VTE risk assessment
Less than 11 C. Difficile
infections
(Report in Quality Account the
number of C. difficile infections
per 100,000 bed days)
Patient experience
Priority 8
Priority 9
Priority 10
Reduction in chemotherapy
waiting times and improvement
in patient experience related to
waiting times
*Ensure that we are responding
to in-patients’ personal needs
*Percentage of staff who would
recommend The Royal Marsden
to friends or family needing care*
Reduction in chemotherapy
waiting times at Sutton and
Chelsea and improvement in
the patient experience related to
waiting times
Improvement in responses
to five questions (in the CQC
national survey described
above) as monitored through
the Inpatient Frequent
Feedback Surveys
Introduce a Patient Experience
survey for SMCS
To maintain or increase the
staff survey result to this
specific question in the survey.
To achieve a baseline
measurement and if possible
benchmark with other
community services
Patient experience
Priority 11
Priority 12
^Improve communication, particularly when
patients arrive for first appointments
^Reduce the length of time a patient waits for
medicines or equipment at the point of discharge
Increase or maintain the high percentage of
positive comments in dedicated patient feedback
Increase or maintain the high percentage of
positive comments in dedicated patient feedback
Childrens services
Effective care
Priority 4
Priority 5
Priority 6
Priority 7
Priority 13
Reduction in
community acquired
grade 3 and 4 pressure
ulcers: applies to SMCS
Increase the number
of patients that die
in their preferred
place of death (The
National Primary Care
Snapshot Audit in End
of Life Care (2009)
found that the number
of patients achieving
their preferred place of
death is 42%) Applies
to acute and SMCS
Increase the numbers
of patients who have
an Holistic Needs
Assessment
*Avoidance
of emergency
re-admissions to
hospital within
28 days of discharge.
^The uptake of immunisation working in partnership with primary care
Achieve more than
42% of patients dying
in their preferred place
of death.
Increase the proportion
of designated patients
who will be offered
a Holistic Needs
Assessment by the
end of 2013/14
Reduce the incidence
of severe community
acquired pressure
ulcers (grade 3 and 4)
42
Increase the percentage of children receiving pre-school immunisations in partnership with GPs
(*) mandatory priority
(^) new quality priorities
Reduction in the
number of avoidable
re-admissions
to hospital within
28 days of discharge
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The Royal Marsden NHS Foundation Trust
Quality Account 2012/13
The table below summarises the quality objectives and priorities of the Trust for the last four years.
Community services are detailed from 2011/12 onwards.
Safety
2009/10
2010/11
2011/12
2012/13
Incidence of healthcare
associated infections
Reduction of
healthcare associated
infections
Reduction of
healthcare associated
infections
*Reduction in
Healthcare Associated
Infections
Reduction in
medication errors
Reduction in
medication incidents
Reduction in
medication incidents
*Rate of patient
safety incidents and
percentage resulting in
severe harm or death
Incidence of falls
Reduction in falls
Reduction in falls.
(hospital services)
A 15% increase
in number of falls
screens compared
to 2010/11 (SMCS)
Assessment,
monitoring and
treatment of venous
thromboembolism
Reduction in venous
thromboembolism
(blood clots)
Compliance with
national health
visiting targets: new
birth visits (SMCS)
Effective care
2009/10
2010/11
2011/12
2012/13
Mortality rate, hospital
standardised mortality
ratio (HSMR)
Reduction in the
hospital standardised
mortality ratio (HSMR)
Reduction in the
hospital standardised
mortality ratio (HSMR)
Reduction in the
hospital standardised
mortality ratio (HSMR)
Incidence of
hospital acquired
pressure ulcers
Reduction in
the incidence of
hospital acquired
pressure ulcers
Reduction in
the incidence of
hospital acquired
pressure ulcers
(hospital services)
Reduction in
community acquired
grade 3 and 4
pressure ulcers
Reduction in pressure
ulcers especially
grades 3 and 4 (SMCS)
Achieve more than
42% of patients dying
in their preferred
place of death
Effective length of stay
*Percentage of
admitted patients risk
assessed for venous
thromboembolism
Reduced length of stay
Reduced length of stay
Increase the numbers
of patients who
have been offered
an Holistic Needs
Assessment
*Reducing the
number of emergency
re-admissions to
hospital within
28 days of discharge
Safeguarding children
priorities – compliance
with national guidance
and training (SMCS)
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The Royal Marsden NHS Foundation Trust
Quality Account 2012/13
Statements of assurance from the Board
Patient experience
2009/10
2010/11
2011/12
2012/13
Patients in pain
To be in top 20% of
trusts for key areas
on the national
inpatient survey
To be in top 20%
of trusts for key
areas of national
inpatient survey
*Improve or maintain
a high score in
relation to responding
to inpatients’
personal needs in
the national survey
Patients treated with
dignity and respect
To be in top 20% of
trusts for key areas
on the national
outpatient survey
To be in top 20%
of trusts for key
areas of national
outpatient survey
Patients given
enough information
on discharge
Roll out of the real
time patient feedback
throughout the Trust
Roll out of the real
time patient feedback
throughout the Trust
New initiatives to
improve the patient
experience in 2011/12.
1) To reduce
chemotherapy
waiting times,
Review of services
During 2012/13 The Royal Marsden NHS Foundation Trust provided and/or sub-contracted
comprehensive cancer services.
The Royal Marsden NHS Foundation Trust has reviewed all the data available to them on the quality
of care in 100% of these services.
The income generated by the NHS services reviewed in 2012/13 represents all of the total income
generated from the provision of NHS services by The Royal Marsden NHS Foundation Trust for 2012/13.
The data reviewed in part three of this Quality Account covers the three dimensions of quality: patient
safety, clinical effectiveness and patient experience. In all areas the data has been available to review
the service.
Participation in clinical audits
Reduction in
chemotherapy
waiting times and
improvement in patient
experience related
to waiting times
2) To improve the
patient experience of
hospital transport,
National clinical audits and national confidential enquiries are tools that NHS organisations
use to assess the quality of services provided, against the best available evidence based
guidance and standards.
At The Royal Marsden we undertake many clinical audits. We participate in all the national cancer
audits which are applicable to the organisation. This allows us to benchmark against other hospitals in
England and sometimes across the world. We also have a comprehensive programme of local clinical
audits which clinical staff including consultants, junior doctors, nurses and allied health professionals
conduct regularly to improve local areas of care.
During 2012/13 11 national clinical audits and three national confidential enquiries covered NHS
services that The Royal Marsden provides.
3) To improve
communication at
every part of the
patient journey
National confidential enquiries
*Percentage of staff
who would recommend
The Royal Marsden
to friends or family
needing care
These are “inspections” that are carried out nationally to investigate areas of care where there may have
been problems nationally or where the patients may be particularly vulnerable. All hospitals are asked to
take part in them so that all care across England can be monitored.
During 2012/13 The Royal Marsden participated in all 11 of the national clinical audits and three
national confidential enquiries in which it was eligible to participate (Table 1). Many of the national
audits undertaken by other hospitals cannot be undertaken at The Royal Marsden because we only have
patients with cancer.
The national clinical audits and national confidential enquiries that The Royal Marsden participated
in, and for which data collection was completed for the period 2012/13, are listed below alongside the
number of cases submitted to each audit or enquiry as a percentage of the number of registered cases
required by the terms of that audit or enquiry (Table 1 and 3).
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The Royal Marsden NHS Foundation Trust
Quality Account 2012/13
Table 1: National clinical audits The Royal Marsden participated in 2012/13
No
National Clinical Audits
Participated
Cases submitted (%)
1
National Comparative Audit of Blood
Transfusion: Blood sampling and labelling
Yes
100%
2
National Oesophago-Gastric
cancer audit (NOGCA)
Yes
100% input of those
diagnosed at the Trust
3
The National Bowel Cancer
Audit (NBOCAP)
Yes
100% input of those
diagnosed at the Trust
4
Lung Cancer (National Lung Cancer Audit)
Yes
Note: Tertiary Trust
Standards do not apply as
most patients are not “first
seen” at tertiary trusts
5
Head and Neck Cancer (DAHNO)
Yes
100%
6
Intensive Care National Audit &
Research Centre (ICNARC) Case
Mix Programme (CMP)
Yes
100%
The reports of 13 national clinical audits were reviewed by The Royal Marsden in period 2012/13.
The Royal Marsden will take the following actions to improve the quality of healthcare provided.
Table 2: National clinical audits published reports and actions taken in 2012/13
No
National Clinical Audit reports
published in 2012/13
Description of actions
1
National Lung cancer Audit Report 2011
None. Treatment practice exceeds
national standards. (Diagnosis is not
undertaken at The Royal Marsden)
2
National Head & Neck Cancer
Audit 2011: 7th Annual Report
Recommendations reviewed
3
National Oesophago-Gastric
Cancer Audit Report 2012
Recommendations reviewed
4
National Bowel Cancer Audit Report 2012
Recommendations reviewed
5
2011 Audit of the medical use of red cells
Report reviewed
6
2012 Audit of blood sampling and labelling
Report reviewed
7
NHSCSP Audit of invasive cervical
cancer National report 2007-2011
Report disseminated
NHS Breast Screening Programme
& ABS An audit of screen detected
breast cancers for the year of screening
April 2010 to March 2011
Report disseminated
8
NCIN (National Cancer Intelligence
Network) Recurrent and Metastatic
Breast Cancer Data Collection
Project, Pilot report, March 2012
Recommendations reviewed
9
Findings of the UK national audit
evaluating image-guided or image assisted
liver biopsy. Part I. Procedural aspects,
diagnostic adequacy, and accuracy
Report disseminated
10
Findings of the UK national audit evaluating
image-guided or image assisted liver biopsy.
Part II. Minor and major complications
and procedure-related mortality 2009/10
Report disseminated
11
RCR Summary Report of the Results
of the Royal College of Radiologists’
National Breast Radiotherapy Audit
Reviewed by members
12
RCR National Oesophago-Gastric
Cancer Audit – 2012 Annual Report
Report disseminated
13
BAUS section of oncology
Report disseminated
Other National Audits
7
The Association of Breast Surgery (ABS)
& NHS Breast Screening Programme
Yes
100%
8
Breast Cancer Clinical
Yes
100%
Outcome Measures (BCCOM) Project
9
National Health Service Cancer
Screening Programme (NHSCSP)
Audit of Invasive Cervical Cancer
Yes
Ongoing data-collection
for quarterly submission.
100% input of those
treated at the Trust
10
Royal College of Radiologists (RCR) National
Re-audit of Radiotherapy in the Treatment
of Malignant Spinal Cord Compression
Yes
100%
11
The British Association of Urological
Surgeons (BAUS) Nephrectomy audit
Yes
100%
Analyses of Nephrectomy dataset
1 January – 31 December 2011, June 2012
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The Royal Marsden NHS Foundation Trust
Quality Account 2012/13
Table 3: National confidential enquiries The Royal Marsden eligible to participate in
No
National Confidential Enquiry into Patient
Outcome and Death (NCEPOD) studies
Participated
% cases submitted
1
Alcohol related liver disease
Yes
100%
2
Subarachnoid haemorrhage
Yes
100%
3
Tracheostomy care (pilot)
Yes
100%
The reports of two national confidential enquiries report were reviewed by The Royal Marsden in
2012/13. The Royal Marsden intends to take the following actions to continue to improve the quality
of healthcare provided.
Table 4: National Confidential Enquiries reports published in 2012/13 and actions
No
National Confidential Enquiry into Patient
Outcome and Death (NCEPOD) studies
Description of actions (local)
1
Bariatric Surgery: Too Lean
a Service? (2012)
Not applicable. Bariatric surgery for weight loss
2
Cardiac Arrest Procedures:
Time to Intervene? (2012)
Recommendations reviewed
The reports of 88 local clinical audits and local action plans to improve the quality and outcomes of
patient care were reviewed by The Royal Marsden in 2012/13.
Participation in clinical research
The Royal Marsden, The Institute of Cancer Research and Mount Vernon Cancer Centre form the largest
centre for cancer research in Europe. This is important because it means that our patients and our staff
are always aware of the latest research in treatments, medicines and therapies that make such a major
difference to outcomes and the experience of care. If you would like to find out more about our research
work please go on to our website on www.royalmarsden.nhs.uk
The number of patients receiving NHS services provided or subcontracted by The Royal Marsden in
2012/13 that were recruited during that period to participate in research approved by a research ethics
committee was 7,274 patients into 307 different trials.
Revalidation of doctors
Revalidation began in December 2012. The Trust has been preparing for this for some time and reported
good progress on the Organisational Readiness Self-Assessment (ORSA) as at March 2012, with a
delivery plan to ensure the four outstanding items are in place by the end of 2012. Of these four key
tasks two have been fully implemented, with the others updated to reflect recent changes. The process
to ensure doctors provide information from their work at other organisations in their appraisal portfolio
has been revised based on further guidance and is being implemented in a consistent manner with
neighbouring trusts. The policy for the reskilling, rehabilitation and remediation of doctors has been
updated based on recent guidance and is progressing through the implementation stage. An electronic
system to support revalidation has been procured and is now being rolled out. The appraisal system has
been enhanced and is tightly monitored with the rates of completed appraisals improving. The Trust’s
Responsible Officer has been revalidated and other doctors will begin to be revalidated from May 2013.
The Trust’s progress to a ‘revalidation ready’ state is managed through clear governance arrangements
and has been reported and discussed at all levels and relevant forums including the Trust Board.
Use of the CQUIN payment framework
The Commissioning Quality and Innovation (CQUIN) payment framework is a method that the NHS
introduced in 2009/10 to reward hospitals and other NHS services for taking quality and innovative
patient care initiatives seriously. If hospitals did not achieve their CQUIN targets then, in 2010/11, 1.5%
of a hospital’s income was removed and, in 2011/12, 2.5%. In challenging financial times for the NHS it
is important that quality initiatives are linked to a financial lever to ensure that the front line staff and
the Board are able to prioritise quality care. For a list of the CQUIN targets for 2012/13 and then 2013/14
please go on to the CQUIN page on our website via www.royalmarsden.nhs.uk or contact us via the
Head of Quality Assurance on 020 7808 2702 and we can post details out to you.
A proportion of The Royal Marsden NHS Foundation Trust’s income in 2012/13 was conditional
on achieving quality improvement and innovation goals agreed between The Royal Marsden NHS
Foundation Trust and any person or commissioning PCT they entered into a contract, agreement
or arrangement with for the provision of NHS services, through the Commissioning for Quality and
Innovation payment framework.
In 2012/13 The Royal Marsden achieved 100% of its CQUIN target which is £3 million.
In 2011/12 The Royal Marsden achieved 93% of its CQUIN target which is £1.7 million.
In 2012/13 Sutton and Merton Community Services achieved 86.7% of its CQUIN target which is £712,474.
In 2011/12 Sutton and Merton Community Services achieved 90% of its CQUIN target which is £418,000.
Further details of agreed goals for 2012/13 and for the following 12 month period are available online at:
http://www.monitor-nhsft.gov.uk/sites/all/modules/fckeditor/plugins/ktbrowser/_openTKFile.php?id+3275
Or at The Royal Marsden website: www.royalmarsden.nhs.uk
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The Royal Marsden NHS Foundation Trust
Quality Account 2012/13
What others say about the provider
Information Governance Toolkit attainment levels
Statements from the Care Quality Commission (CQC)
The Royal Marsden score for 2012/13 for Information Quality and Records Management assessed
using the Information Governance Toolkit was 88%. This marks an improvement on the interim
submission score in October 2012 of 86%. Furthermore, the Trust scored a minimum of Level 2 on all 45
requirements. Our final position is: satisfactory (Green). The Information Governance Toolkit is available
on the Connecting for Health website (www.igt.connectingforhealth.nhs.uk).
The Royal Marsden NHS Foundation Trust is required to register with the Care Quality Commission and
its current registration status is “registered with no conditions”.
The Care Quality Commission has not taken enforcement action against The Royal Marsden NHS
Foundation Trust during 2012/13.
The Royal Marsden NHS Foundation Trust has not participated in any special reviews or investigations
by the CQC during the reporting period, 2012/13.
Data quality
Good quality information is very important in underpinning the effective delivery of the best patient care.
The Royal Marsden NHS Foundation Trust submitted records during 2012/13 to the Secondary Uses
service for inclusion in the Hospital Episode Statistics which are included in the latest published data.
The percentage of records in the published data, which included the patient’s valid NHS number, was
98.7% for admitted patient care, 98.8% for outpatient care, and none for accident and emergency care
(specialist cancer trust without an accident and emergency).
The percentage of records that included the patient’s valid General Practitioner Registration Code was
98.9% for admitted patient care, 98.9% for outpatient care and none for accident and emergency.
Data quality – England and Wales
The Royal Marsden NHS Foundation Trust was not to subject the Payment by Results clinical coding
audit during the reporting period by the Audit Commission.
Clinical coding
Coding Errors
Primary Diagnosis Errors
Primary Procedure Code Errors
Secondary Diagnosis Errors
Second Procedure Code Errors
2009/10
2010/11*
2011/12**
2012/13**
5.0%
2.5%
3.5%
8.0%
35.7%
2.1%
12.4%
4.7%
7.2%
1.9%
2.9%
5.1%
12.8%
8.4%
26.4%
8.8%
* The Trust was not eligible for an Audit Commission Clinical Coding Audit in 2010/11; these figures are therefore based on an audit
commissioned by The Royal Marsden in November 2010.
% completeness
NHS number
Clinical coding error rate
** These figures are draft pending the final report from the Audit Commission for the 2012/13 audit.
GP practice
2010/11
2011/12
2012/13
2010/11
2011/12
2012/13
Inpatient & Day cases
98.6
98.6
98.7
99.0
99.0
98.9
Outpatients
98.6
98.8
98.8
98.9
99.1
98.9
Although Data Quality at The Royal Marsden is very good the Trust strives for continual improvement.
The Royal Marsden NHS Foundation Trust implements the following actions to improve data quality:
1. A dedicated data quality team are responsible for running routine validation checks and reports to
identify errors and inconsistencies in data entry
2. In 2013 Trust wide monthly communications started promoting the importance of accurate
information and data collection centrally for all Trust staff
3. Trust wide audits of data quality involving key information points are conducted annually.
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The Royal Marsden NHS Foundation Trust
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Quality Account 2012/13
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The Royal Marsden NHS Foundation Trust
Quality Account 2012/13
Part four
NHS 18 week targets
Target/ Priority
Review of quality performance (previous year’s performance)
National targets
National
target
2012/13
2012/13
performance
Q1
2012/13
performance
Q2
2012/13
performance
Q3
2012/13
performance
Q4
2012/13
performance
Cancer waiting
times targets
All urgent GP referrals
seen within 14 days
93%
95.3%
98.0%
99.0%
97.6%
97.5%
All referrals for
breast symptoms
seen within 14 days
93%
93.0%
89.2%
96.3%
97.1%
94.7%
Treatment within 31
days of decision to
treat for first treatment
96%
98.8%
99.5%
99.2%
99.3%
99.2%
Subsequent surgical
treatment started
within 31 days of
decision to treat
94%
96.2%
96.1%
96.8%
98.2%
96.8%
Subsequent drug
treatment started
within 31 days of
decision to treat
98%
99.5%
99.8%
100%
100%
99.8%
Subsequent
radiotherapy treatment
started within 31 days
of decision to treat
94%
95.6%
96.4%
98.8%
99.3%
97.6%
Treatment started
within 62 days of
urgent GP referrals*
85%
86.6%
86.1%
87.3%
83.3%
85.9%
Treatment started
within 62 days
of recall date for
urgent screening
centre referrals
90%
94.4%
90.6%*
95.7%
92.5%
93.2%
National
target
2012/13
2010/11
%
achieved
2011/12
%
achieved
2012/13
%
achieved
National
target
2013/14
Patients requiring admission
who waited <18 weeks from
referral to treatment (not
national targets since 2010)
90%
94.90%
94.8%
96.0%
90%
Patients not requiring
admission who waited
<18 weeks from referral
to treatment (not national
targets since 2010)
95%
98.40%
98.8%
98.6%
95%
Access targets
National target
2010/11
% achieved
2011/12
% achieved
2012/13
% achieved Q1
2012/13
% achieved Q2
2012/13
% achieved Q3
2012/13
% achieved Q4
National target
2013/14
Target/ Priority
Operations cancelled
by the Trust at
the last minute
Less
than
5%
0.3%
0.3%
0.16%
0.15%
0.36%
0.22%
Less
than
5%
Last minute
cancelled operations
not subsequently
performed within
one month
0%
0%
0%
0%
0%
0%
0%
0%
The Royal Marsden NHS Foundation Trust met all key performance waiting times and access targets
in 2011/12 and 2012/13.
* Figures include agreed reallocations between Trusts
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The Royal Marsden NHS Foundation Trust
Quality Account 2012/13
Appendix 1
Number
Quality Indicators where national data is available from
the Health and Social Care Information Centre (HSCIC)
Period
The
Royal
Marsden
National
highest by %
(all specialist
trusts)
National
lowest by %
(all specialist
trusts)
Average
specialist
trusts
The Trust considers this data is as described as taken from the Health and Social Care Information Centre.
October 2011 – March 2012
2
6
*0
4.4
The Trust has taken actions to improve the percentage and so the quality of its services (see priorities
for each indicator in Part 2 for further information).
April 2011 – September 2011
5
11
*0
2.1
The tables below shows how the trust compares against other trusts and shows the highest and lowest
national scores.
Quality Indicators
A. The data made available to the National Health Service trust or NHS foundation trust by the
Health and Social Care Information centre with regard to the rate per 100,000 bed days of
cases of C. difficile infection reported within the trust amongst patients (Trust Priority 1).
Period
The
Royal
Marsden
National
highest (all
acute and
specialist
trusts)
National
lowest (all
acute and
specialist
trusts)
Average
acute
trusts
England
national
April 2011 – March 2012
30
51.6
*0
-
21.8
April 2010 – March 2011
56.6
71.8
*0
29.6
* The Trust is advised that the zero recorded here may be due to missing data reported to the centre.
C. The data made available to the National Health Service trust or NHS foundation trust by the Health
and Social Care Information Centre with regard to the percentage of patients who were admitted
to hospital and who were risk assessed for venous thromboembolism during the reporting period
(Trust Priority 3).
Period
The
Royal
Marsden
National
highest (all
acute and
specialist
trusts)
National
lowest (all
acute and
specialist
trusts)
Average
acute
trusts
England
national
Q3 2012/13
97
100
84.6
-*
94.1
Q2 2012/13
97
100
80.9
-*
93.8
* The Trust is advised that the zero recorded here may be due to missing data reported to the centre.
* The Trust is advised that the zero recorded here may be due to missing data reported to the centre.
D. The data made available to the National Health Service trust or NHS foundation trust by the Health
and Social Care Information Centre with regard to the percentage of patients aged – i) 0-14; and
ii) 15 or over, readmitted to a hospital which forms part of the Trust within 28 days of being discharged
from a hospital which forms part of the Trust during the reporting period (Trust Priority 7).
B. The data made available to the National Health Service trust or NHS foundation
trust by the Health and Social Care Information Centre Incidents reported within
the trust during the reporting period and the number and percentage of such patient
safety incidents that resulted in severe harm or death (Trust Priority 2).
Percentage
Period
The
Royal
Marsden
National
highest (all
specialist
trusts)
National
lowest (all
specialist
trusts)
Average
specialist
trusts
October 2011 – March 2012
0.1
2.9
0
0.6
April 2011 – September 2011
0.3
4.6
0
0.3
Period
The
Royal
Marsden
National
highest
(all trusts)
National
lowest (all
trusts)
Average
specialist
trusts
England
national
2010/11 standardised
to persons 2006/07
7.94
17.33
*0
9.52
11.42
2009/10 standardised
to persons 2006/07
6.7
22.09
*0
9.45
11.16
* The Trust is advised that the zero recorded here may be due to missing data reported to the centre.
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E. The data made available to the National Health Service trust or NHS foundation trust by the Health
and Social Care Information Centre with regards to the trust’s responsiveness to the personal needs
of its patients during the reporting period (Trust Priority 9).
Period
2011/12
2010/11
The
Royal
Marsden
National
highest
(all trusts)
National
lowest (all
trusts)
Average
specialist
trusts
England
national
82.8
85
56.5
*-
67.4
82
82.6
56.7
*-
67.3
* The Trust is advised that the zero recorded here may be due to missing data reported to the centre.
F. The data made available to the National Health Service trust or NHS foundation trust by the Health
and Social Care Information Centre with regard to the percentage of staff employed by, or under
contract to, the trust during the reporting period who would recommend the trust as a provider of
care to their family or friends (Trust Priority 10).
Period
The
Royal
Marsden
National
highest (all
specialist
trusts)
National
lowest (all
specialist
trusts)
Average
acute
trusts
England
national
2012
87
94
62
65
63
2011
85
96
66
65
60
Appendix 2
Statements from
key stakeholders
Statement from Patient and Carer Advisory
Committee on the Quality Account
Robert Francis QC, in his letter to the Secretary
of State submitting his final report of the Mid
Staffordshire NHS Foundation Trust Public
Inquiry, described a Trust that did not listen
sufficiently to its patients and staff. The report
made several recommendations surrounding
openness and transparency. Robert Francis also
wrote about the need to develop and share ever
improving means of measuring and understanding
of performance of hospitals.
The Royal Marsden’s Quality Account for the
period 2012/13 is the fourth report published by
the Trust. This Quality Account demonstrates
that the Trust remains focussed on listening to its
patient, carer and staff community. It continues to
strive to improve the quality of care and its services
within the framework of its regulators. The
document also makes clear The Royal Marsden’s
commitment to be an organisation that does
measure and understand its performance, meeting
we believe, a vital recommendation of the Francis
Public Inquiry. Importantly, the Quality Account
sets out detailed quality priorities and targets for
the period 2013/14.
The Patient and Carer Advisory Committee
commend this Quality Account.
Charles McGregor
Chairman of Patient and Carer Advisory Group
Statement from the Council of Governors
on the Quality Account 2012/13
The Council of Governors routinely reviews
information prepared for inclusion in the
Quality Account and has discussed the chosen
priority quality issues at each of the Council of
Governors meetings.
A sub-group of the Council of Governors, the
Patient Experience and Quality Account Group,
has also reviewed feedback from patients,
including from the frequent feedback surveys,
and has influenced the questions used in these
surveys, to reflect patients’ interests.
Governors agreed the process for developing and
selecting priorities for quality improvement and
have met with patient, carer and public members
at two Members’ Events, in July and November
2012. At these meetings, round table discussions
were held to obtain members’ views on current
and future areas relating to patient safety, clinical
effectiveness and patient experience. The results
were then formulated into priority topics for
inclusion in the forthcoming Quality Account
and submitted to the full Council of Governors
for approval.
Dr Carol Joseph, Public Governor for Kensington
and Chelsea served as the representative from
the Patient Experience and Quality Account
Group, which was responsible for monitoring the
development of the Quality Account throughout
the year.
The Royal Marsden strives to improve the
presentation of data each year to make the Quality
Account, now in its fourth year of publication,
more succinct, interesting, and readable by
the general public as well as by healthcare
professionals. This year the Group of Governors
have seen a considerable improvement in the
layout of the information, making it easier to read
and digest.
Based on their involvement and the feedback they
have received from members and other patients
and carers, Governors endorse the key priorities
for improvement as set out in the Quality Account.
Dr Carol Joseph
Public Governor for Kensington and Chelsea
60
61
The Royal Marsden NHS Foundation Trust
Statement from NHS South West
London on the Quality Account
The Quality Account shows and reflects the
huge amount of effort and commitment from
all in the organisation to improve the quality
of services in an already highly performing trust.
It should give great assurance to all who use
The Royal Marsden.
Dr Tony Brzezicki
Chair of The Royal Marsden Clinical Quality
Review Group
Quality Account 2012/13
Healthwatch Central West London response
to The Royal Marsden NHS Foundation
Trust Quality Account 2012/13
Healthwatch Central West London (CWL)
welcomes the opportunity to comment on
The Royal Marsden NHS Foundation Trust’s
Quality Account (QA) 2012/13.
Prior to the commencement of Healthwatch (April
2013), K&C LINk Cancer sub group had ongoing correspondence with The Royal Marsden
throughout 2012/13 with RMFT represented on the
cancer sub-group.
Statement from Sutton Health and Wellbeing Board on the Quality Account
Page number*
Comment(s)
12 second bullet point
“across almost all”: can you clarify use of “almost” (or express as a
percentage) explaining why those areas which are not audited are not part
of the scheme.
22
Is the target sufficiently stretching when performance has substantially
achieved it?
24/25
With the low response rates for some conditions have you undertaken any
work to try to understand why? Is it that the process could be more sensitive
to patient needs / is the form too off-putting or complicated? Are staff at
some locations using better techniques to get better responses? Are some
conditions ‘naturally’ more likely to generate a response?
We would like to commend the Trust for their work
on VTE risk assessment; however we would also
like the Trust to further outline whether or not they
intend on implementing thrombosis alert cards for
outpatient and day patients.
Healthwatch CWL would like clarity about how
the Trust intends on monitoring the use of Holistic
Needs assessment (HNA) as there is a seemingly
low compliance rate of 38%. There does not seem
to be a plan outlined to clarify what the trust will
be implementing to review the leaflet, its ease of
use, accessibility nor whether it addresses low and
no literacy issues.
Whilst we commend the trust for consistently
low readmission figures, the figure for July 2012
(22) shows a significant increase upon previous
months, we would like the trust to explain further
what remedial process was put into place to
alleviate this from recurring.
Healthwatch CWL would like to suggest that the
new patient experience leaflets outlined in priority
8 for patient experience are co-produced between
the Trust and patients.
Healthwatch CWL very much looks forward
to continuing our strong working relationship
with The Royal Marsden NHS Foundation
Trust in 2013/14, particularly engaging with
patients and members to take part in the new
PLACE assessments.
Note: For further information on this statement please contact
Melanie Christodoulou, Interim coordinator, Healthwatch CWL on
email: melanie.christodoulou@hestia.org or call 020 8968 7049
The quarterly response rate figures deteriorate quite significantly in quarter
3 of 2012/13 (and were below target). Some explanation or comment on this
would be helpful.
It would be helpful for the narrative to make some comment on these figures.
Particularly in light of the comments above the actions planned are
expressed in too general a fashion.
26
This section would benefit from more narrative explanation particularly of
the high and low months of July and December and some comment on what
might be done to rectify.
30
The fact that a full third of patients were not told how long they would have
to wait is concerning. As well as the other planned actions could you also
consider offering indicative waiting times so that people would at least have
some guide.
32/33
The fact that just under and just over a quarter of patients could not find
someone to talk to about worries and fears (Q34) and were told about side
effects (Q56) is concerning. Further narrative explaining what is being done
to improve these areas would be helpful.
42
Targets for some priorities need to be expressed more robustly e.g. Priority 5
should set a new target value (see also point above re p.22) as a percent not
simply to improve on the value set last year. See also Priorities 6 and 7.
53
Is it possible to provide some explanation and comments on improvement
actions in relation to the significant increase in errors between 2010/11
and 2011/12 for ‘primary procedure code errors’ and ‘second procedure
code errors’.
Councillor Mary Burstow
Chair Sutton Health and Wellbeing Board
*Sutton Health and Wellbeing Board commented on a draft of the Quality Accounts dated 25 March 2013.
The page numbers have been adjusted to correlate with this final version.
62
63
The Royal Marsden NHS Foundation Trust
Response from Merton Clinical Commissioning
Group to The Royal Marsden NHS
Foundation Trust Quality Account
Merton Clinical Commissioning Group reviewed
the Quality Account from The Royal Marsden
NHS Foundation Trust at its Clinical Quality
Meeting on 12 April 2013. Merton CCG is the
host commissioner for the Sutton and Merton
Community Services and commissions this
community contract on behalf of Sutton CCG and
the London Boroughs of Sutton and Merton and
Public Health & the NHS England.
Merton CCG recognises that the quality account
covers both the acute hospital and community
services, however we will comment solely on
the community services aspect of the report.
We recognise that much of the content of the
quality account is mandated by the Department
of Health and we regret that this makes some of
the document rather technical and therefore less
accessible to the lay reader. In terms of clinical
care, the CCG was pleased to see the focus both
on the very young and the elderly, with schemes
relating to preventing pressure ulcers, choice
of place of death and improving support to
mothers after birth. We also welcome the focus
on improved immunisation and vaccination take
up rates for 2013/14.
Quality Account 2012/13
Within the CCG, our GPs are very keen for the
local district nursing teams and other allied
health professionals to work with them in a closer
and more responsive and integrated way than
has been the case over the last two years. To
this end, we have asked The Royal Marsden to
present their development plans for the community
service to the CCG for discussion. We will be
monitoring progress in achieving the targets
set out in this quality account – as well as more
general improvement goals – closely over the
forthcoming year.
Jenny Kay
Director of Quality
Eleanor Brown
Chief Officer
Appendix 3
Statement of Director’s
responsibilities in respect
of the Quality Account
The Directors are required under the Health
Act 2009 and the NHS (Quality Accounts)
Regulations 2010 to prepare Quality Accounts for
each financial year. Monitor has issued guidance
to NHS Foundation Trust Boards on the form
and content of annual quality reports (which
incorporate the above legal requirements) and on
the arrangements that Foundation Trust Boards
should put in place to support the data quality for
the preparation of the Quality Account.
In preparing this Quality Report directors have
taken steps to satisfy themselves that the content
of the Quality Report meets the requirements set
out in the NHS Foundation Trust Annual Reporting
Manual 2012/13.
The quality of the Quality Report is consistent
with internal and external sources of
information including:
–– Board minutes and papers for the period
April 2012 to May 2013
–– Papers relating to quality reported to the Board
over the period April 2012 to May 2013
–– Feedback from the commissioners dated
25 April 2013
–– Feedback from the Governors through the
Council of Governors throughout the year
dated 15 April 2013
–– Feedback from Healthwatch Central West
London (during 2012/13 known was Kensington
and Chelsea Local Involvement Network)
dated 15 April 2013
–– The Trust’s complaints report published
under regulation 18 of the Local Authority
Social Services and NHS Regulations 2009,
dated 24 April 2013
–– The 2012 national in-patient survey results
–– The 2012 national staff survey
–– CQC quality and risk profiles throughout
April 2012 to March 2013
–– The Quality Report presents a balanced picture
of The Royal Marsden NHS Foundations Trust’s
performance over the period covered
–– The performance information reported in the
Quality Report is reliable and accurate
–– There are proper internal controls over the
collection and reporting of the measures of
performance included in the Quality Report, and
these controls are subject to review to confirm
that they are working effectively in practice
–– The data underpinning the measures of
performance reported in the Quality Report
is robust and reliable, conforms to specified
data quality standards and prescribed
definitions is subject to appropriate scrutiny
and review; and the Quality Report has been
prepared in accordance with Monitor’s annual
reporting guidance (which incorporates the
Quality Accounts regulations) published at
www.monitor-nhsft.gov.uk/annual reporting
manual as well as the standards to support
data quality for the preparation of the Quality
Report (available at www.monitor-nhsft.gov.uk/
annualreporting manual).
The directors confirm to the best of their knowledge
and belief they have complied with the above
requirements in preparing the Quality Report.
By order of the Board
Mr R. Ian Molson
Chairman
19 June 2013
Cally Palmer CBE
Chief Executive
19 June 2013
–– The Head of Internal Audit’s annual opinion
over the Trust’s control environment dated
29 May 2013
64
65
The Royal Marsden NHS Foundation Trust
Appendix 4
Independent
Assurance Report
Independent Auditor’s Report to the Council
of Governors of The Royal Marsden NHS
Foundation Trust on the Quality Report
We have been engaged by the Council of
Governors of The Royal Marsden NHS
Foundation Trust to perform an independent
assurance engagement in respect of
The Royal Marsden NHS Foundation Trust’s
Quality Report for the year ended 31 March 2013
(the “Quality Report”) and certain performance
indicators contained therein.
This report, including the conclusion, has been
prepared solely for the Council of Governors of
The Royal Marsden NHS Foundation Trust as
a body, to assist the Council of Governors in
reporting The Royal Marsden NHS Foundation
Trust’s quality agenda, performance and activities.
We permit the disclosure of this report within the
Annual Report for the year ended 31 March 2013,
to enable the Council of Governors to demonstrate
they have discharged their governance
responsibilities by commissioning an independent
assurance report in connection with the indicators.
To the fullest extent permitted by law, we do not
accept or assume responsibility to anyone other
than the Council of Governors as a body and
The Royal Marsden NHS Foundation Trust for our
work or this report save where terms are expressly
agreed and with our prior consent in writing.
Scope and subject matter
The indicators for the year ended 31 March 2013
subject to limited assurance consist of the national
priority indicators as mandated by Monitor:
–– Clostridium difficile;
–– Maximum 62 day waiting time from urgent GP
referral to treatment for all cancers.
We refer to these national priority indicators
collectively as the “indicators”.
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Quality Account 2012/13
Respective responsibilities of the Directors
and auditors
The Directors are responsible for the content and
the preparation of the Quality Report in accordance
with the criteria set out in the NHS Foundation
Trust Annual Reporting Manual issued by Monitor.
Our responsibility is to form a conclusion, based
on limited assurance procedures, on whether
anything has come to our attention that causes us
to believe that:
–– the Quality Report is not prepared in all material
respects in line with the criteria set out in the
NHS Foundation Trust Annual Reporting Manual;
–– the Quality Report is not consistent in all
material respects with the sources specified in
the guidance; and
–– the indicators in the Quality Report identified as
having been the subject of limited assurance in
the Quality Report are not reasonably stated in
all material respects in accordance with the NHS
Foundation Trust Annual Reporting Manual and
the six dimensions of data quality set out in the
Detailed Guidance for External Assurance on
Quality Reports.
We read the Quality Report and consider whether
it addresses the content requirements of the NHS
Foundation Trust Annual Reporting Manual, and
consider the implications for our report if we
become aware of any material omissions.
We read the other information contained in
the Quality Report and consider whether it is
materially inconsistent with the documents
specified within the detailed guidance. We
consider the implications for our report if we
become aware of any apparent misstatements or
material inconsistencies with those documents
(collectively the “documents”). Our responsibilities
do not extend to any other information.
We are in compliance with the applicable
independence and competency requirements of
the Institute of Chartered Accountants in England
and Wales (ICAEW) Code of Ethics. Our team
comprised assurance practitioners and relevant
subject matter experts.
Assurance work performed
We conducted this limited assurance engagement
in accordance with International Standard
on Assurance Engagements 3000 (Revised) –
“Assurance Engagements other than Audits or
Reviews of Historical Financial Information”
issued by the International Auditing and
Assurance Standards Board (“ISAE 3000”).
Our limited assurance procedures included:
–– Evaluating the design and implementation of the
key processes and controls for managing and
reporting the indicators
–– Making enquiries of management
–– Testing key management controls
–– Limited testing, on a selective basis, of the
data used to calculate the indicator back to
supporting documentation
–– Comparing the content requirements of the
NHS Foundation Trust Annual Reporting Manual
to the categories reported in the Quality Report
The scope of our assurance work has not included
governance over quality or non-mandated
indicators which have been determined locally by
The Royal Marsden NHS Foundation Trust.
Conclusion
Based on the results of our procedures, nothing
has come to our attention that causes us to believe
that, for the year ended 31 March 2013:
–– the Quality Report is not prepared in all material
respects in line with the criteria set out in the
NHS Foundation Trust Annual Reporting Manual;
–– the Quality Report is not consistent in all
material respects with the sources specified
in the guidance; and
–– the indicators in the Quality Report
subject to limited assurance have not been
reasonably stated in all material respects in
accordance with the NHS Foundation Trust
Annual Reporting Manual.
–– Reading the documents.
A limited assurance engagement is smaller 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.
Deloitte LLP
Chartered Accountants
St Albans
20 June 2013
Limitations
Non-financial performance information is
subject to more inherent limitations than
financial information, given the characteristics
of the subject matter and the methods used for
determining such information.
The absence of a significant body of established
practice on which to draw allows for the selection
of different but acceptable measurement
techniques which can result in materially different
measurements and can impact comparability. The
precision of different measurement techniques may
also vary. Furthermore, the nature and methods
used to determine such information, as well as the
measurement criteria and the precision thereof, may
change over time. It is important to read the Quality
Report in the context of the criteria set out in the
NHS Foundation Trust Annual Reporting Manual.
67
The Royal Marsden NHS Foundation Trust
Appendix 5
Glossary of terms
Antibiotic
Medicines used to treat
bacterial infections.
Bacteraemia
The presence of bacteria in
the blood.
Care Quality
Commission (CQC)
Regulates all health and adult
social care services in England,
including those provided by
the NHS, local authorities,
private companies or voluntary
organisations. It also protects
the interests of people detained
under the Mental Health Act.
Chemotherapy
Treatment with anti cancer
drugs to destroy or control
cancer cells.
Clinical champion
An expert nurse, doctor or
therapist who is responsible for
promoting an area of health care.
Clinical coding
The process whereby
information written in the patient
notes is translated into coded
data and entered onto hospital
information systems. Coding
usually occurs after the patient
has been discharged from
hospital, and must be completed
to strict deadlines in order that
hospitals can receive payment
for their activity.
Commissioning for Quality
and Innovation (CQUIN)
The CQUIN payment framework
enables commissioners to
link a proportion of English
healthcare providers’ income to
the achievement of local quality
improvement goals.
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Quality Account 2012/13
Computed Tomography (CT)
A medical imaging method.
Customer Service Excellence
(CSE) Standard
The Government’s customer
service standard. This scheme
replaces the Charter Mark.
CyberKnife
A robotic method of delivering
radiotherapy, with the intention
of targeting treatment more
accurately than standard
radiotherapy.
DAHNO
Data for Head and Neck
Oncology.
Datix
Proprietary web-based reporting
system used to record incidents,
complaints and patient comments.
Enhanced Recovery
Programme
A national scheme that places
the patient at the centre of a
multi-professional team to plan
for greater partnership in care,
improved quality of care and
shorter lengths of stay in hospital.
Foundation trust
Foundation trusts have a
significant amount of managerial
and financial freedom when
compared to NHS hospital
trusts. They are considered
mutual structures akin to cooperatives, where local people,
patients and staff can become
members and governors and
hold the Trust to account.
Health Protection Agency
(HPA)
Helps protect UK public health
by giving support and advice
to the NHS, local authorities,
emergency services, the
Department of Health and any
other organisations that play a
part in protecting health.
Healthcare-associated
infections (HCAIs)
An infection acquired during the
course of healthcare.
Local Involvement Networks
(LINk)
Have been replaced by
Healthwatch from April 2013.
Healthwatch
The new independent consumer
champion to gather and
represent the views of the public.
Will play a role at national and
local level. Healthwatch England
will work with local Healthwatch
and has the power to recommend
that the CQC take action where
there are concerns about health
and social care services.
Local Children’s Safeguarding
Boards
Bring together local agencies
to work together to protect
vulnerable children.
Hospital Standardised
Mortality Ratio (HSMR)
An indicator of healthcare
quality that measures whether
the death rate at a hospital is
higher or lower than expected.
Hygiene Code
The Health and Social Care
Act 2008 Code of Practice for
health and adult social care
on the prevention and control
of infection.
ICR
Institute of Cancer Research.
Information governance
Ensures that organisations
achieve good practice with data
protection and confidentiality.
Integrated governance
Systems and processes by
which trusts lead, direct and
control their functions in order
to achieve organisational
objectives, safety and quality
of service.
Key Performance Indicators
Used by an organisation
to evaluate its success or
the success of a particular
activity in which it is engaged.
Sometimes success is defined
in terms of making progress
toward strategic goals, but often
success is simply the repeated
achievement of some level of
operational goal.
Multi-disciplinary team (MDT)
A group of healthcare
professionals from different
disciplines who work together.
Membership Council
A council of members consisting
of elected and nominated
representatives who assist in
governing The Royal Marsden
NHS Foundation Trust.
Metastatic
A cancer that has spread to
other organs from the original
tumour site.
Meticillin-resistant
Staphylococcus aureus
(MRSA) and Clostridium
difficile (C. difficile)
Bacteria that are a
significant cause of hospital
acquired infections.
Monitor
The independent regulator
of NHS foundation trusts.
The National Confidential
Enquiry into Patient Outcome
and Death (NCEPOD)
An independent charitable
organisation that reviews medical
and surgical clinical practice
and makes recommendations to
improve the quality of the delivery
of care for the benefit of the public.
National Patient Safety
Agency (NPSA)
Shares learning from patient
safety incidents occurring in
the NHS.
NCIN
National Cancer
Intelligence Network.
National Institute for Health
and Clinical Excellence (NICE)
Reviews medicines, treatments
and tests. It makes clinical
guidelines and public health
recommendations.
Health and Wellbeing board
Has replaced the overview
and scrutiny functions of local
authorities and have the power to
call witnesses from local National
Health Service (NHS) bodies
and make recommendations
that NHS organisations must
consider as part of their decisionmaking processes.
Patient Advice and Liaison
Service (PALS)
Provides information, advice and
support to help patients, families
and their carers. Each NHS
Trust has a PALS service.
Patient and Carer
Advisory Group
Works to improve the
experience of patients at
The Royal Marsden. It is a
self-managed group of patients,
carers and members of the
public who play an integral part
in the continuing improvement
of care and services provided
by the Trust.
Pressure ulcers
Bed sores or pressure sores.
Prophylaxis
A measure taken to prevent
a disease or condition.
Pulmonary embolism (PE)
A blockage of a blood vessel
in the lung.
Radiotherapy
The use of high energy rays to
destroy cancer cells. It may be
used to cure some cancers, to
reduce the chance of recurrence
or for symptom control.
RCR
Royal College of Radiologists.
SMCS
Sutton and Merton Community
Services.
Venous thrombo-embolism
(VTE)
Blood clot typically occurring
in leg but which can form in any
blood vessel.
VitalPac system
Software to detect deterioration
in patients.
Patient Environment Action
Team (PEAT)
Perform assessments focusing
on the environment in which
care is provided and the quality
of non-clinical services such as
food and privacy and dignity.
Picker Institute Europe
An organisation that administers
patient surveys including the
frequent feedback surveys which
gather data from patients in real
time using hand-held devices.
69
The Royal Marsden NHS Foundation Trust
Life demands excellence.
At The Royal Marsden, we deal with cancer every
day so we understand how valuable life is. And
when people entrust their lives to us, they have
the right to demand the very best.
That’s why the pursuit of excellence lies at
the heart of everything we do. No matter what
we achieve, we’re always striving to do more.
No matter how much we exceed expectations,
we believe we can exceed them still further.
We will never stop looking for ways to improve
the lives of people affected by cancer. This attitude
defines us all, and is an inseparable part of the
way we work. It’s The Royal Marsden way.
You can visit, write to or call The Royal
Marsden using the following details:
Chelsea, London
The Royal Marsden
Fulham Road
London SW3 6JJ
Tel 020 7352 8171
Sutton, Surrey
The Royal Marsden
Downs Road, Sutton
Surrey SM2 5PT
Tel 020 8642 6011
www.royalmarsden.nhs.uk
70