The
Quality Account
2012-13
Putting Patients First
2
Contents
Part 1
Chief Execuve Statement
5
Quality Review
7
1.1 A Review of Quality Performance in 2012/13
8
1.2 Our Quality Priories for Improvement during 2013/14
14
Reducing Inpaent Falls
14
Prevenng Avoidable Pressure Ulce rs
14
Safe and Effecve Discharge
14
Non-Inpaent paent expe rience
14
Communicaon with paents, re laves, GPs and Community Teams
14
1.3 Other qua lity measures which remain a high priority
15
Hospital Standardised Mortality Rao (HSMR)
15
Cleanliness and Hygiene
15
Paent Safety
16
Paent Services
17
Paent Flow
18
Reconfiguraon of Services
18
Workforce a nd Educaon & Learning
19
Unders tanding Culture and Lea rning from Francis Report
21
1.4 Looking ahead
Part 2
22
Mandatory Statements
23
2.1 Key Performance Indica tors
24
2.2 Statements of Assurance
25
2.3 Parcipaon in Clinical Audit
28
2.4 Parcipaon in Clinical Research
29
2.5 Data Qua lity
29
2.6 Use of the Commiss ioning for Quality and Innovaon (CQUIN) payment framework
31
2.7 Care Quality Commission (CQC) regis traon and compliance
33
Annex 1
Statements from Comm issione rs, Shrops hire and Telford & Wrekin LINKs and Overview and Scruny
Commi6ees
Annex 2
Statement of Dire ctors Responsibilies
Annex 3
External Audit Lim ited Assurance Report
Annex 4
Glossary of Te rms
Putting Patients First
3
Putting Patients First
4
Chief Execuve statement
Quality, experience, safety and outcomes clearly must be the
central driving principles for every NHS trust. He re at T he Knowing what we do today about demands for health se rvices,
Shrewsbury and Telford Hospital NHS Trust we have set out our I personally believe that this organisaon would not come to
the same conclusions as last year when it decided to reduce
clear commitment through our vision of Pu;ng Paents Firs t.
bed capacity (and the staffing associa ted with this). Our
Joining the Trust during the year, several things I was very keen paents have felt the impact of this and our staff have also felt
to understand were how we are pe rforming, what our paents this impact. However, I am confident that we are m uch closer
think about us and what the ir real experience is within our to ge;ng it right as a health and care system.
wards, clinics and departments. I also wante d to know wha t
inspires and movates our staff to always strive to give of their It’s crical that we focus on the culture of the organisaon and
ensure tha t this is founde d on the values of the Six C’s - Care,
best.
Compassion, Courage, Communicaon, Compete nce and
Commitme
nt. As Chief Execuve, this will be my first priority
This Quality Account is a vital and valuable snapshot of these
for
the
year
ahead – to e nsure, engage, empower, and
various themes. It shows issues and areas whe re we have
encourage
a
culture
in this T rust whe re everyone feels able to
progressed well and made improvements such as a reducon in
provide
the
highes
t
s tandards of care every me for every
falls resulng in se rious harm, the introducon of a frail and
paent.
complex se rvice, and improvements in our discharge pathways.
These are clearly things that we need to build on, but there a re
also many othe r a reas whe re s ignificant improvement is sll I want us to be a Trust which has the courage to be open when
things go wrong and to have the compete nce to de liver what is
needed.
expected and needed from us, whethe r we are providing
My commitment as Chief Execuve as I begin my first full year frontline care or supporng those that do.
with the Trust is to ensure that this is an organisaon that is
relentless in its pursuit of the paent’s interests. Excee ding the We need to ensure communicaon that is truly and fully
expectaons of our paents and the communies that we serve focused on the needs of the paent in front of us and their
family and loved ones, and that we have the compassion to
must always be wha t drives us.
always be present in the mome nt for the people we care for
In orde r to do this, the Quality Account sets out the priority and work with.
areas that we need to focus on. These have been driven and
idenfied by our paents, pa rtne r organisaons and staff and by I want us to have the commitment to always give of our best,
comparing ourselves with how other organisaons across the and last but not least, to be a caring organisaon that always
NHS and beyond a re delivering consistently high standards of Puts Paents First.
care.
They include a focus on communicaon with our paents,
relaves, GPs and comm unity teams, and ensuring paents have
a safe and effecve discharge from hos pital. Other priories
include connuing to reduce the numbers of paent falls, and
the ongoing reconfiguraon of inpaent se rvices to mee t the
changing needs of our paents.
Declaraon
The Secretary of Stat e has directed that the Chief Execuve should
be the Accountable Officer for the Trust. The responsibilies of
Accountable Officers include accountability for clinical governance
and hence the quality and safety of care delivered by the Trust. To
the best of my knowledge and belief the Trust has properly
discharged its responsibilies for the quality and safety of care, and
the informaon presented in this Quality Account is accurate.
It is clear tha t in some areas of quality we have not delivere d the
standards that our paents and communies have the right to
expect. I think the re are two key issues that sit at the hea rt of
this. The first is culture, which I will return to late r. The second is
capacity and flow.
It has been very clear that a big challenge for us, and also for the Peter Herring
whole health and care system, has been the ability to meet, in a Chief Exe cuve Officer
mely way, the urgent and eme rgency care needs of our
communies. This issue is re flected throughout the Quality
Account, and it is a s ignificant contributory factor in ca ncelle d
operaons and an increase in pressure ulce rs, and has had a n
impact on paent e xperience.
This is why for me, ensuring that both within a nd outside
hospitals we have got the right plans and the right capacity in
place to deliver compassionate urgent ca re has been a
significant focus during my first few months in pos t.
Putting Patients First
5
Putting Patients First
6
Part 1
Quality Review
Putting Patients First
7
1.1
A Review of Quality Performance in 2012 - 2013
In last year’s Quality Account we outlined seven quality priories for 2012/13. For each priority we have provided a report
outlining the work undertaken within the Trust to underpin the im provements require d.
Current Status
of Priority
Comment
Further Details
on Page
Prevenng a voidable pressure ul cers
Despite connued focus on pressure
ulcer prevenon we have not
eradicated grade 3 and 4 hospital
acquire d pressure ulcers over the
last year.
We have however,
complete d
a
baseline
data
collecon of grade 2 ulce rs and
commenced Root Cause Analysis on
these.
9
Reducing Inpa ent Falls
A reducon was achieved in overall
falls plus falls resulng in serious
harm was re duced by 25%. Plus
94% of paents received a comfort
round.
10
Sa fer Blood Transfusion
Improvements in training have bee n
achieved, however observaons
have not demons trated the
required improvement
10
Using Paent Invol vement to
Improve Paent Experience
• A wide variety of work has been
undertaken by the PEIP over the
last year.
• The Friends and Family queson
has been comple ted for 10% of
discharged paents each week.
• Ward to Board surveys have
expanded with m ore planne d for
the next 3 m onths
11
Improving the Experience of Frail
Elderl y Pa ents
The Frail and Comple x Service was
launched successfully at the Royal
Shrewsbury Hospital in Decembe r
2012 and at the Princess Royal
Hospital in January 2013
11
Providing Effecve Diabetes Ca re to
Our Pa ents
• Good progress with e lea rning
training with applicaon for
Cerficate of Achievement being
progressed by the T rust.
• Single point les ions developed
• Paent expe rience survey for
diabec paents com plete d
• Awareness day he ld which was
very successful
12
Improving the Pa ent Journey
• Expected Date of Discharge
furthe r embedde d and now
supported by PSAG
• Improvements
made
in
Outpaent Expe rience
13
Quality Priority 2012/13
Putting Patients First
8
Update on Quality Priories in
2012/13
1. Prevenng Avoidable Pressure Ulcers
Why was this a priority?
Last year we commi6ed to eliminate avoidable
Grade 4 pressure ulce rs by De cember 2012 and
Grade 3 pressure ulcers by March 2013. We have
not achieved this and the refore must unders tand
why we have not achieved our ta rget in orde r to
ensure that we achieve s ignificant and
demonstra ble im provements in 2013/14.
The Trust is fully commi6ed to achieving this
priority as we recognise that the delivery of harm
free care is as important to our paents as it is to
us. Therefore we must and will provide an
environment of safe and effecve pressure area
care to all paents at risk
What were our goals for 2012-2013?
Last year we comm i6ed to elim inate avoidable Grade 4
pressure ulcers by De cember 2012 and all avoidable Grade 3
pressure ulce rs by March 2013.
We also said that we would do more to understand the numbe r
of grade 2 pressure ulce rs and to improve the numbe r of
paents who received an assessment of the ir skin within 2
hours of admission.
What have we achieved?
We have expe rience d a 63% increase in reporng of Grade 4
pressure ulce rs and a 100% increase in reporng grade 3
pressure ulcers. These figures however have not been fully
adjusted as they reflect all hospital acquire d press ure ulcers
including those that were clinica lly unavoidable. To ensure a
transpare nt process is followe d, any pressure ulcers deemed
by the Trust to be unavoidable are then put forward for
raficaon by our Clinical Comm issioning Groups.
The majority of all Grade 3 and Grade 4 Pressure ulcers
reported s ince 01/01/2013 appea r to fall into the category of
being unavoidable (sll pe nding invesgaon). Since
01/01/2013 the Trust has declared three (3) Grade 4
pressure ulcers, two (2) of which a re s uspecte d as being
unavoidable at the me of reporng. However, as outlined
above these would a ll re quire raficaon and would remain
reported as avoidable within T rust data unl agreed
otherwise.
The process of confirming unavoidable pressure ulce rs with
our Commissioners has inially idenfied two (2) g rade 3
pressure ulcers as matching the crite ria for unavoidability
(and the refore are not include d in the figures idenfied), and
a furthe r 11 ulcers that are currently going through the
raficaon process.
Grade 3 Grade 4
Confirmed SaTH (avoidable)
16
8
Unavoidable
(confirmed by Commissioners)
2
0
Awaing raficaon (invesgaon in
progress within organisaon)
1
0
Pending raficaon (with Commissioners to confirm as unavoidable)
11
5
What more do we need to do?
Reducing and prevenng hospital acquired pressure ulce rs is
seen as a priority not only naonally, but als o locally. Included in
this priority is not only the elim inaon of avoidable Grade 3 and
4 pressure ulce rs, but als o to s ignificantly reduce the number of
Grade 2 avoidable pressure ulce rs that are hospital acquired.
From Septembe r 2012 Grade 2 pressure ulcers were more
closely monitore d and a Root Cause Analysis is now completed
for each one. Validaon of the gra ding is comple ted, and in just
over 50% of cases the inial grading is classified as not T rust
acquire d, moisture l esion or not a pressure ulcer. This assists
the Trust in understa nding the sca le of the target to be achieved
and acons that will be required to achieve those
improvements.
All ward based nursing staff com plete a pressure ulcer
prevenon workbook and are supported by our Tissue Viability
Team with expert knowledge to de liver ca re. The Trus t also
ensures that staff a re s upported to a6e nd formal post graduate
ssue viability training with Staffordshire University. In the year
ahead pra ccal pressure ulcer prevenon training will be
included within the “Fundamentals of Care” day which is
describe d in more detail late r in the Quality Account.
The Trus t has developed a Pressure Ulcer acon plan which will
be delivere d in full over the coming year. Examples of acons
include;
•
•
•
•
Expanding our Tissue Viability team to provide an
improved level of support and training to our staff
Launching a Pressure Ulce r Prevenon Group, chaired by
the Corporate Nursing Team
The Fundamentals of Care study day will be manda tory
for ward based s taff.
Nursing documentaon improved to support staff in
making decisions a bout pressure area care.
We connue to use the Safety The rmomete r and Pressure Ulcer
reporng data to monitor and report our performance.
Putting Patients First
9
2. Further Reducon of Inpaent Falls
Why was this a priority?
It is recognised that paent falls in hospital have the potenal
to lead to loss of confidence, se rious injury, and exte nded stays.
It is also widely recognised that paents may be at higher risk of
falling in the hospital environment than they would be in their
own homes due to the less fam iliar change in environment.
Adult inpatient falls incidents
200
iav
d
150
et
r
o
p
100
er
st
50 xi
n
e ta
d
ic D
in 0
fo
r
eb
m
u
N
20 12/ 2013
2011/ 2012
Month
What more do we need to do?
In recognion of the se rious ness of the risk to paents arising
from fa lls in hospital, in February 2013 the T rust Boa rd
approved a corporate acon plan aimed at re ducing falls
resulng in significant ha rm in hospital, which will form a major
programme of work for the T rust in the coming financial year.
This work will be monitored regularly by the Quality and Safety
Commi6ee and the Falls Task Group.
Some typical e xamples of the work pla nned for the current year
are:
•
A major programme of falls prevenon e -learning for
ward-based staff;
•
A larger tria l of bed and chair pressure sensors, and a
separate trial of one -way slide sheets for use in bedside
chairs;
•
The introducon of a new style of falls risk assessment
and care planning which it is hoped will lead to more
individua lised care plans for paents judged to be at risk
of falls.
2010/ 2011
3. Safe Blood Transfusion
Why was this a priority?
Previous audits and m onitoring pe rformance (including naonal
benchmarking) showe d there we re three main areas relang to
blood component transfusion that should be im proved to
increase paent safety and also meet a naonal demand to
reduce wastage of this pre cious com ponent as blood stocks are
low.
What were our goals for 2012-2013?
Our quality priority was to connue to achieve a year-on-year
reducon in adult inpaents falls (excluding spontaneous fits,
faints and collapses) which we had achieved in the previous two
financial years.
We also said that we would reduce falls resulng in se rious
harm by 25% and that we would e nsure that 100% of paents
received a comfort round according to their needs.
What were our goals for 2012-2013?
1. Reduce the number of sampling errors
What have we achieved?
2. Ensure we record paents vital signs at the right me, every
In the financial year 2011/ 2012, we recorde d a total of 1590
me
adult inpaent falls e xcluding spontaneous fits, faints and 3. Waste less blood compone nts
collapses. In the financial year 2012/ 2013 we recorde d a
total of 1562 sim ilar incidents, which represents a modes t
reducon.
Notably, the pa 6ern of month-on-month
reducon was s ustained from April 2012 to January 2013, but
not for February and March 2013 which this year more closely
reflecte d the seasonal pa6e rn for the year 2010/ 2011 than
the year 2011/ 2012 as we saw an increase in emergency
acvity during this pe riod. During March 2013 we also saw a
75% increase in the num ber of Frail and Com plex paents
being admi6e d to our hospitals for more than 48 hours.
In the financial year 2011/ 2012, we reported a total of 29
falls resulng in serious injury to the Health and Safety
Execuve unde r the Reporng of Injuries, Diseases and
Dangerous Occurre nces Regulaons 1995 (RIDDOR). In the
financial year 2012- 2013 we reported a total of 22, which
represents a re ducon of approximately 25%.
The Trust’s Falls Group connued to be acve in prog ressing
falls prevenon measures across the hos pitals. The year’s
acvies have included a small-scale trial of be d pressure
sensors and a larms, a trial of a new style of falls risk
assessment on Ward 16 (informe d heavily by the naonal
FallSafe research project which was published in July 2012 by
the Royal College of Physicians), and connued oversight of
the lessons learned from the Trust’s root cause analysis
invesgaons into falls resulng in serious ha rm.
Putting Patients First
10
What have we achieved?
Training
Medical staff re cording of the ory assessment commence d
in August 12 and was inially 37.7%. In the six months
from baseline, we have achieved a s teady increase to 52%.
Nursing/support staff reached 85.6% compliance in Augus t
12, however has since reduced slightly to 83% mainly due
to new staff starng and some two yearly compe tency
assessments expiring which a re awaing rene wal.
Sampling errors
10% reducon in overall re jecons
15% reducon in serious e rrors
Monitoring of vital s igns
Monthly spot check audits matche d the results of 140
transfusions in May 12, which means tha t we have not
improved in this area. The increase in com pliance in the
March 13 audit is prom ising and we m ust maintain a focus
on this to ensure sustained im provement.
Red cell was tage has been reduced by 27% through a
change in blood collecon by Portering staff. However
plasma wastage has been increased poss ibly due to
implementaon of the naonal massive haemorrhage
protocol. It is hoped that tha t this will show a reducon
over the next year.
What more do we need to do?
• A systemac review of how to achieve the sampling
competency assessment so that it is robust and effecve.
This will ensure that through training and educaon staff
sample corre ctly by unders tanding processes and impact
on outcomes for paents.
• Review a proposal for introducing an electronic add-on
program to the BloodTrack system for safe sampling.
• Review processes of accountability for incidences of
incorrect sampling and monitoring (and/or documenng)
paents vital signs.
• Transfusion training to be priorised by supporng link
nurses to take on training of their own staff as this is not
sustainable by the transfus ion praconers.
• Agree an acon plan to improve plate let wastage.
• Reinforce a culture of not carrying out a transfusion if
there is ‘no me to pe rform basic safety checks’ (nonacute situaons)
• To improve compliance of re cording vital signs.
A trial is being piloted over the com ing months, the results
of which will be fe d back to Matrons for disseminaon and
acon to benchmark our standards of pracce with othe r
Trusts across our region.
we also need to consolidate the role that the paent
representaves have in the reviewing and monitoring of care
What were our goals for 2012-2013?
•
Paent Experience and Involvement Panel (PEIP), to be
involved in the monitoring and review of care de livery
ulising a com prehe nsive programme of work.
•
The implementaon of the F riends and Family tes t across
inpaent areas with the aim of achieving a 10% response
rate and a ten point increase on the April 2012 benchmark
score. Our benchma rk figure was set in April 2012 at
63.12 , we achieved 75.7 for March 2013.
•
Expansion of the ward to boa rd metrics to outpaent and
speciality areas s uch as Outpaents and Renal Unit.
•
Develop clear acon plans to address the issues idenfied
in both inpaent and outpaent surveys
What have we achieved?
The paent represe ntave panel has recruited representaves
with a varie ty of special interes ts and backgrounds to increase
the size and strength of the group.
Panel membe rs have connued to build on last years comprehensive work programme and have been involved in a
collecon of paent stories, observaons of care, quality
assurance frameworks and audits of paent mealmes. Over
the last year panel members have been included in the
recruitment process for senior nursing roles within the
corporate team and have also been co-opted onto the project
board of the Booking and Sche duling boa rd.
We have implemented the Friends and Family Test across all
inpaent areas, and in doing so achieved a response rate
averaging above 20% and a ten point increase on our April
2012 benchmark score.
Monthly Outpaent sasfacon surveys are collected to allow
monitoring of the areas in which the trust score d less we ll in
the naonal survey. This has informed the review of the
Outpaent acon plan. The s urvey results s how a sustained
improvement in the e leven quesons asked.
The trus t has conducted quarte rly inpaent quesonnaires in
which the quesons asked have been designed to focus in on
the areas in which the trust scored lowest in the Naonal
Survey 2011.
What more do we need to do?
We will connue the work with de partments to improve the
paent experience in the areas idenfied in the inpaent survey
results. We will also expand the Friends and Family test to
Maternity and Eme rgency Department services during 2013/14.
We must sustain and im prove upon the level of involvement of
PEIP members across a range of acvies within the Trust.
5. Improving the Experience of Frail Elderly Paents
4. Using Paent Involvement to Improve Paent
Experience
Why was this a priority?
We currently re ceive feedback from our paents in a variety
of ways which we can then use to make improvements in
the way that we deliver our se rvices. Moving forward we
need to involve paent representaves in the development
of our services to deliver an enhance d paent experience,
Why was this a priority?
The Frail and Complex Service is one of the 4 key transformaonal
change programmes within the Shropshire Unschedule d Care
Strategy 2011-2014.
The Frail and Comple x Service provides a joint approach between
hospital and community health and socia l care staff to ensure that
paents are ge;ng the right care in the right place at the right
me.
Putting Patients First
11
Naonally over the next 20 years, the numbe r of pe ople aged 85
and over is set to increase by 66% compa red with a 10% growth in
the overall populaon. Older people are admi6e d to hos pital more
frequently, have longer length of stay and occupy more be d days in
acute hos pitals compare d to other individual groups. They
have the highest readmission ra tes and highest rates of long term
care use aSe r dis charge.
In addion, key local reasons for change include: •
The need to provide an high quality, financially efficient
service.
•
Reduce the reliance on hospital beds and care for frail and
complex paents in a comm unity se;ng whe rever possible
•
Improved support for paents from community care
resources
•
Current fragmented services are failing to mee t the needs of
the populaon
What were our goals for 2012-2013?
“To achieve the best outcomes for frail olde r pe ople through
an integrated health and social ca re whole systems
approach with inter-disciplinary/agency teams who
understa nd the comple x needs of this paent group,
delivering a range of intervenons at differe nt stages along
the paent journey from prevenon and early idenficaon
through to services that manage acute illness (or
exacerbaons of chronic illness) without resorng to
admission to specia list services in acute hos pitals. Health
and social care services are stra tegically a ligned with s hared
leadership within a joint regulatory and governance
framework”.
Programme Descripon of the Frail and Complex Service
This is a three year project. Much of 2012-13 was spent
establishing the foundaons for integrated working across the
health and social care e conomy. T he specific ope raonal aim for
What have we achieved?
Following a se ries of monthly s takeholde r workshops and
operaonal meengs including paent representaves, the RSH
Frail and Complex Service commenced on the 3rd De cember
2012 with the PRH F rail and Complex Service commence d on
28th Janua ry 2013
2012-13 was to launch this new way of working in both of SaTH’s
acute hos pitals.
What more do we need to do?
The launch of the service in the acute hospitals is only stage 1 of
the se rvice development programme. The next crical step is to
roll out the service across the county to strengthe n the ‘admission
avoidance’ element of the work on a more equitable basis for
Shropshire res idents and to ta rget over 14 day length of stay
paents in SaTH to strengthen the earlier supporte d discharge
focus. The Frail and Complex Team have just begun demena
screening to s upport CQUIN requirements and in orde r to work
more close ly with colleagues in the RAID service as there is
conside rable overlap in this paent group. Running parallel to this
is the nee d to explore a cve case management in GP Pracces,
work in partnership with Powys health board to develop a s imilar
model of care and develop single point of access and a demand and
capacity informaon hub
6. Providing Effecve Diabetes Care to Our Paents
paents eithe r directly or indirectly through carers and
relaves. 1 in 5 paents admi6ed to our hospitals have
diabetes. Following the impleme ntaon of the “Think
Glucose” campaign across the Trust during 2011, several
areas for increased aware ness and improvement have
been highlighted for focus across all 3 domains of quality
during 2012/13 with the overall a im being to reduce
incide nts relang to the pres cribing and adm inis traon of
Insulin and to improve outcomes and experiences for
paents with Diabetes.
What were our goals for 2012-2013?
We will see a reducon in the number of prescribing and
administraon errors recorde d on DATIX, the Trust’s
incide nt reporng system. This will be achieved by the
following;
• 80% of appropriate s taff will complete the learning
modules as outlined by the NPSA
• Single Point Lessons will be developed and made
available to staff which act as a quick refere nce guide
and will cover a varie ty of subjects such as;
complicaons of diabetes pres cribing insulin,
managing emergency situaons.
• An awareness campaign led by the Endocrine
Consultants and Diabetes Nurse Specialis ts which is
supported by the boa rd which focuses on specific
diabetes re lated subjects and incorporang and
awareness day and road show for a variety of staff
• A survey of diabec paents to capture their
experie nce of care delivered by the Trust
• An audit of ide nfied inpaent areas against Key
Performance Indica tors
What have we achieved?
We have seen a slight increase in the number of errors
recorded on the DATIX system. This may however be a
reflecon of the increased awareness of diabe tes
related issues with in the trust.
A review in October 2012 showe d that 135 members of
trust medical and nursing s taff have com pleted the
module on safe use of variable rate insulin infusions and
537 members of trust medical and nursing staff have
complete d the safe use of insulin m odule
We have developed single point lesson plans, which
have been developed for all the key areas relang to
diabetes. In addion we established an aware ness
campaign led by the Endocrine Consulta nts and
Diabetes Nurse Specialists which is supported by the
board and focuses on specific diabetes related s ubjects.
In November; a repeat paent experie nce quesonnaire
was sent out to 200 paents with diabe tes tha t had
been in to hospital since April 2012. The results of this
showed:
• 3% improvement in mely monitoring of blood
glucose levels
• 19% improvement in paents ability to self
administe r diabe tes medicaon whilst in hospita l
• 12% improvement in accessibility of me dicaons in
order for self me dicaon purposes
• 14% drop in overall sasfacon with care.
Why was this a priority
Diabetes is a condion that affects a significant proporon of
Putting Patients First
12
What more do we need to do?
The diabetes team will be monitoring the DATIX reports
received regarding diabetes within the trust in addion to
review of medicaon incidences re ported via E -script and will
report twice yearly to the Clinical Governance Execuve
regarding performance and progress. The trust will need
connue to support the 80% compleon of the online diabetes
modules by all medical and nursing s taff. In addion these
registers will s ub categorise d to each clinical area in orde r to
target a reas tha t do not reach the 80% compliance target. The
diabetes team will connue to a udit the clinical areas for
compliance to Think Glucose performance indicators
7. Improving the Paent Journey
Why was this a priority?
We recognise d that the paent’s journey has many steps and
that we need to ensure that these run as seamlessly as
possible. We needed to ens ure that when our paents are
admi6ed to our hos pital that we give them informaon about
when they can expect to go home. For outpaents we needed
to ensure tha t communicate the right informaon at the right
me , whether that is before their appointment or aSer they
have arrived.
What were our goals for 2012-2013?
Undertake a comprehens ive review and revision of the paent
informaon lite rature to ensure that accurate informaon is
available for paents on admission about what they can expect
during their hospita l stay.
We said that 90% of our paents will have had an expe cted
date of discharged comm unica ted across the healthcare team.
This informaon is gathered from our Paent Status at a
Glance screens and discussed on daily board rounds.
We said that paents a6ending for an appointment rece ive
mely and accurate noce of their appointment and tha t once
they have arrived at the department they we re kept updated
about what they can expect to expe rience. We said that we
update our paent experie nce survey to ca pture this
informaon directly from paents. This informaon is gathe red
from our Outpaent survey results
We also said we would improve our Outpaent waing area
signage .
What have we achieved?
•
100% of paents have an Expected Date of Discharge
(EDD), however we need to do more to keep paents
updated.
•
The Paent Informaon Pane l was re launche d and
working with the Libra ry services is developing
database of paent informaon which is accessible,
evidenced based and quality assure d.
•
Monthly outpaent paent feedback surveys have
been complete d which show a consistent im provement in the areas in which the trust have performed
poorly in the 2011 Naonal Outpaent survey.
•
Paent representaon on the Booking and Scheduling
Proje ct Board and
paent representaves
undertaking observaon of care in outpaent’s areas.
•
Paent journey through outpaents reviewed at PRH,
signage and waing areas re configured as an
outcome.
•
Paent representaves involved in the development
of clear outpaent acon plans to improve the
paent journey.
What more do we need to do?
There are many further opportunies for improving the paent
journey and just because we have achieved the points above
does not mean we should stop striving for best pracce in this
area. Our increased focus on improving paent flow in our
hospitals has highlighted several a reas to priorise for
improvement over the com ing months. From the paent's
entrance to the hospital via the Eme rgency De partment or
assessment areas to their dis charge from our wards we have
idenfied opportunies for im provement. A key theme from
this has been the planning and exe cuon of the discha rge
process which is why we have included this as a priority for the
year ahead. Discharge should be safe and effecve every me
and we must make this happen.
With relaon to the outpaent journey we will connue to
work with our paent re presentaves to develop ways of
improving paent flow within the outpaent department. We
will also engage with
hard
to
reach
community interes t
groups, such as young
carers, to seek out
their experie nces of
outpaents and how
we can improve our
services to them.
Putting Patients First
13
1.2
Our Quality Priories for Improvement for 2013 - 2014
How we developed our Quality Priories for 2013/14
Through engagement with our staff and with e xternal stakeholders we have listened to what ma6ers to our paents and s taff
and this is reflected in the priories below. These priories span the 3 domains of quality; Paent safety, clinical effecveness and paent
experie nce and also reflect key areas of feedback for us such as the naonal inpaent survey.
Paent Safety
Clinical Effecveness
Paent Experience
Why is this a priority?
Where are we now?
Reducing inpaent
falls resulng in
serious harm
Prevenng avoidable
pressure ulce rs
Safe and effecve
discharge every me
Communicaon with
relaves and carers
Non inpaent paent
experie nce
Although
we
have
successfully reduced our
overall falls 2 years in a
row and achieved our
goal for reducon in
falls resulng in serious
harm last year, there is
sll work to do to
reduce
these
falls
further and to address
some common themes.
Although much work has been
done to eliminate grade 3
and 4 pressure ulcers and
reduce grade 2 ulcers, we sll
have not achieved our goal in
this area. Therefore we must
connue to priorise this very
important work unl we
achieve success.
We
have
experi enced
increased pressure on our
emergency servic es which in
turn means that the flow of
paents through the hospital
on their journey of care has
been affect ed. Discharge can
oSen be a complex process,
requiring several processes to
be followed by our staff and
other partner organisaons.
We know that we do not
always discharge our paents
well and must work hard to
ensure that discharge is safe
for paents and their carers.
We know that through our
complaints, feedback and
paent experi ence work and
also through our inpaent
survey that we need to
improve on the informaon
we give relav es and
carers. This may be about
discharge or about paents
condions and ongoing care,
where to access help and
support if you care for
someone with demena, or
even about vising in
hospital and what to expect.
Much of our paent
experience work involves
inpaent areas and whilst
this is highly valuable and
must connue we also need
to ask our paents in other
areas of the hospital what
their views are and get their
feedback on the service
they receiv e.
We achiev ed the reducons we set out to do in
last year’s
quality
account and through
the increased focus on
falls resulng in serious
harm have id enfied
key trends and themes
that will form th e focus
of our work over the
coming year.
Last year there were 28 grade
3 and 13 grade 4 ulcers that
were acquired by paents
while under our care.
A
further 2 grade 3 pressure
ulcers were agreed with our
commissioners
as
being
unavoidable and 15 and
currently sll undergoing the
raficaon process (with a
further 2 sll going through
internal verificaon).
A comprehensive work plan is
underway to improve the flow
of paents through the
hospital and to support and
train our staff to ensure we
achieve safe, mely and
effecv e discharge. Esmated
Dates of Discharge are
idenfied and recorded on
our PSAG system for discussion on the daily board round
that occurs on our wards.
Our paent experi ence work
currently involves paents
only and we need to extend
this work to include carers
and relaves.
We have ext ended our
“Friends and Family test”
into areas such as the
Emergency Department and
will be looking to ext end
this to other areas over the
course of the year.
• Reduce fall resulng •
What are our pla ns for 2013-2014?
in serious harm by
25%,
by •
implemenng falls
acon plan.
• Deliver the acons
within the corporate
falls acon plan
which covers the
trends and themes
idenfied, eg;
• Ensure we improve
our processes for
the use of bedrails.
• Standardise
our
handover processes
between
nursing
shiSs
• Develop a falls
service to support
the above plan and
provide
expert
advice and training
Eliminate grad e 3 and 4 • Improved discharge policy
pressure ulcers
by Summer 2013
Reduce grade 2 ulcers by • Strengthened
discharge
50%
team
• Discharge training for every
registered ward nurse by
March 2013
• Improved
discharge
informaon for paents
and
relav es
• Faster internal processes
for simple and complex
discharges
• Audit that paents rec eive
discharge
informaon,
achieving 80% compliance
• Discharge checklists will be
completed for ev ery paent being discharged from
our wards
We wil l report these results in
our monthly quality report
to the Quality and Safety
Commi6ee, and to our
Commissioners
through
Clinical
Quality
Review
meeng.
Putting Patients First
• Develop
a suite of • Connue to roll out our
literature/informaon for
Ward to Board nursing
relav es and visitors.
care
and
paent
experience metrics into
• Expand our paent experithe following non inpaence work to include
ent areas by October
relav es and carers by
2013
developing a range of
quesons similar to those
• Renal Unit
used in our Ward to Board
• Outpaents
survey
Department
• Ensure relaves and
• Ferlity Unit
carers are represented on
• Paediatric Wards
our
Paent Experience
• Neo-natal Unit
and Involvement Panel
• Improve our Paent
• Ensure that we signpost Experience
and
carers of those suffering
Involvement Panel work
from demena to access in non inpaent areas and
help and support services.
also involve our staff in
these areas in dev eloping
We will audit this and wil l
metrics
report these results in our
monthly quality report to We will report these results
the Quality and Safet y in our monthly quality
Commi6ee to ensure that report to the Quality and
we are supporng people Safety Commi6ee, and to
enough in these areas.
our Commissioners through
Clinical Quality
meeng.
14
Review
1.3
Other Quality Measures Which
Remain a High Priority
Hospital Standardised Mortality Rao (HSMR)
The most significant element about both these measures is that
taken together they prove the re has been a tangible reducon
that has bee n achieved by real improvements to paent ca re.
Unders tanding m ortality and how do we measure it
What more can we do?
There has been much that the T rust has achieved in relaon to
With the type of acute care hospita ls such as ours provides it is improving paent care and achieving both tough obje cves we
expected that some paents will die. We acvely monitor our set ourselves. As part of the Leading Improvements in Paent
mortality rates using three measures:
Safety (LIPS) and a joint approach with the West Midla nds
• The Hospital Standa rdised Mortality Rao (HSMR) (1). This is a Mortality Group (WMMG) we had a drive to improve in-hospital
naonal measure and an important means of unde rstanding mortality through the implementaon of care bundles focused
our m ortality against othe r similar hospitals
on specific diseases, these include tackling sepsis and pneum o• The Standard Hospita l Mortality Indicator (SHMI). This is a new nia which are s ignificant ca uses of in-hospital deaths. This has
naonal measure that is being phased in, it is similar in many been successful and we must now turn our a6enon to working
ways to the HSMR but also includes paents who die within 30 with the Clinical Commiss ioning Groups and Community Trus t in
days of being discharged from our hos pital
reducing our mortality further.
• Crude Mortality. This is a local measure and includes all deaths
in our hospita l
The reason for this is that we have idenfie d that the Summary
We report SHMI, HSMR and Crude Rate of mortality to the Trus t Hospital Mortality Indicator (SHMI), a new measure of m ortality
Board as we ll as to the Quality and Safety Commi6ee on a that has re placed the HSMR as the standa rd naonal m ortality
monthly basis.
measure, has not reduced in the same way as the Crude rate of
deaths or the HSMR measure, but shows our Hos pital as be ing
What were our goals during 2012/13?
slightly worse than the Naonal Index. Although we are within
In 2009/10 the T rust was an outlier in the 2011 Dr Fos ter Hospital “expecte d range” for mortality, we a re commi6e d to sustaining
guide and we knew the re were no quick fixes to this problem. our focus in this area this coming year. .
Over the last 2 years we have se t ourselves 2 major objecves
relang to mortality.
As part of this we have formalised our Mortality Group and wid· Reduce our HSMR to the Naonal index by Octobe r 2012
ened it to include Clinical Governance Leads from all Ce ntres in
· Reduce our crude mortality by 350 fewe r deaths within 2 years. the Trust in order to share and collecvely drive improvements
This ends in June 2013.
focussed on SHMI. SHMI informaon can be found on page 24
Where are we now?
We have made s ignificant progress in reducing mortality at
Shrewsbury and Telford Hospitals and we have shown this in
both our m ortality measures that we report to the boa rd each
month.
Cleanliness and Hygiene
Paent Environme ntal Acon Team (PEAT) Inspecons
The formal PEAT assessments for 2012 were unde rtaken on 6
February 2012 at PRH and 28 February 2012 at RSH and results
reported in July 2012 A paent representave and an external
validator joined us on both assessments.
The HSMR was reduced to the naonal inde x in February 2012 The results of the assessments a re shown in the table below.
and connue d to reduce to whe re it is now, at around 95 – 97. Area of Performance:
Environment and Cleanliness
Although this is quite an achievement the re is m uch sll to do.
Metric (Method of
Calculang
Performance):
HSMR (Rolling last 12 months - rebased)
130. 0
Environments/Cleanliness as assessed
by the Environment Acon Team
(PEAT) including a Paent Representave and PEAT Validator
We are pleased to report the following scores for E nvironment,
Food and Privacy and Dignity for 2012
120. 0
110. 0
National Index = 100
Site Name
Environment
Food
Privacy &
Dignity
Royal Shrewsbury
Hospital
Excellent
Excellent
Excellent
Princess Royal Hospital
Excellent
Excellent
Excellent
100. 0
90. 0
A
pr
1
M0
ay
Ju
n
Ju
l
Au
Se g
pt
O
c
N t
o
De v
Ja c
n
11
Fe
b
M
ar
Ap
r
M
ay
Ju
n
Ju
Au l
Se g
pt
Oc
t
No
D v
e
Ja c
n12
Fe
b
M
ar
Ap
r
M
ay
Ju
n
Ju
A l
ug
S
ep
Ot
ct
No
D v
J a ec
n13
80. 0
At the e nd of last year we were prog ressing we ll against our
crude ra te of deaths objecve and this has connued into this
year as well. As it s tands in February 2013, we have achieved 336
less deaths and we have every reason to expect we will achieve
this tough objecve we set ourselves.
From 2013 the PEAT assessment programme has been replace d
with the Paent Led Assessment of the Care Environment
(PLACE) programme. The key change to the assessment format
being to give paents a real voice in assessing the quality of the
healthcare environment.
Putting Patients First
15
The assessments will be ca rrie d out between April and June
and the results will be announced to Trus ts and available from
the Hea lth and Social Care Informaon Ce ntre from September
2013.
Cleanliness, food and general maintenance and décor will
connue to be monitored via our Paent Environment Team.
Feedback from these inspe cons will be presented to the
Paent Environment Group which includes a re presentave
from the Paent Experie nce and Involvement Panel.
Cleanliness
Audits of environmenta l cleanliness standards in wards and
other hos pital areas are undertaken by the Domesc Services
Monitoring Team. Our cleanliness scores a re measured against
the Naonal Standards of Cleanliness and have remaine d high
at 96% for the year from April 2012 to March 2013. A
breakdown of the scores can be found be low: SATH Cl eanliness Score s for 20 12-2013
Percentage
10 0
Average Trus t
Score Per Month
80
60
40
Target Score
The number of incide nts uploaded to the NRLS has increased
slightly from the previous report. The T rust has overall, a
slightly de teriorate d pe rformance in reporng com pared to
other la rge Acute T rusts shiSing from the top third of re porters
to the middle third.
Serious Incidents
Since Janua ry 2011 the Trust has encouraged the reporng all
incide nts using the Dax system and emphasised the
importance of re porng Serious Incidents (SI). This has been
reflecte d in an increase in the numbe r of SI’s reported year-onyear. Trends and themes within the Serious Incide nts are
monitored and offe r opportunies for targeted improvements,
such as pressure ulce rs and falls prevenon.
In 2012/13 the Trust reported 174 Serious Incide nts of which 2
were categorised as Never Events. While this is an increase in
the numbe r of Serious Incidents from 2011/12 it has not
incorporated a Trust rafied total of 10 unavoidable pressure
ulcers, and a possible further 6 that are sll in the process of
being rafied by our commissioners. Following raficaon
unavoidable pressure ulcers can be subtracted from the Trust’s
overall total of Serious Incidents as well as the hos pital acquired
pressure ulce r total.
20
0
March
Febr uary
January
D ec em ber
November
Oc tober
September
A ugust
July
June
May
A pril
The decrease in the numbe r of Never Events, parcularly in the
Ophthalmology service, evidences the improvements in clinical
process and pracce supporte d by a robus t auding process.
Month
Paent Safety
The Trust recognises and values the importance of a culture
where s taff understand the need to re port any incident
affecng either paents, staff or environment. By invesgang
each incident, the organisaon can see what they need to do
to improve and also idenfy trends and themes that need
parcular focus and developme nt of acon plans
% of inciden ts occ uring
Naonally across the NHS, 67% of incidents are reporte d as no
harm and just under 1% as severe harm or death, for La rge
Acute Trusts, 71% of incidents are reporte d as no ha rm and just
under 1% as severe harm or death. However, not all organisaons apply the naonal coding of degree of ha rm in a consistent way which can make comparisons of harm profiles of
organisaons
Figure 3: In cidents rep orted by degree of h arm for large
unreliable.
acute o rgan isations
90
76 .5
SaTH has a
80
71 .5
70
SA TH
reporng rate
60
Al l Large Acute organisations
of 76% of inci50
40
dents
being
30
22.4
reported
as
‘no
1 4.4
20
8.1 5 .3
10
harm’.
0 .7 0.6
0.4 0 .1
0
Non e
L ow
Mo der ate
Se ver e
De ath
Degree of harm
In 2012/13 reporng to the Naonal Paent Safety Agency
(NPSA—via the NRLS) is a volunta ry system (except for ce rtain
categories of very serious incidents), but is cons idere d good
pracce. The Trust reports incidents to the NRLS regula rly
throughout the year. This a llows the Trus t to compare SaTH’s
reporng rate to othe r Trus ts within the large Acute Trust
cluste r.
In line with policy each Serious Incident is invesgated fully with
an Root Cause Analysis and acon plan for improvement
developed. Acon plans belong to the appropriate Centres and
are monitored for compleon within the designated me
frames through ce ntre governance meengs and the High Risk
Scruny Group.
Safeguarding Vulnerable Adults
The Trust connues to provide safeguarding adult protecon
training for all paent handlers and has a chieved 70% overall
compliance with training a6endance across all re levant s taff
groups.
The Trust has insgated one hundred and eleven refe rrals
against external agencies including individual relaves and
carers from April 2012 to March 2013.
From April 2012 to March 2013 the re have been seventy seven
adult protecon referrals raised against the Trust, this included
a significant increase in refe rrals in March 2013 (seventeen in
total), the majority of refe rrals cited the allegaon of neglect
with regard to the discharge of the paent. Over half of the
referra ls were not subs tanated however the inial concerns
were importa nt enough to ra ise a refe rral.
The Trust has we lcomed working with our partners in the
community including the safeguarding teams of both Shropshire
and Telford and Wrekin Councils and also the Clinical
Commissioning Groups. A task and finish group has been established to e xamine the referrals, acons that have been taken
and lessons learned. It will als o look at the appropriateness of
the refe rrals.
In response to the concerns relang to discharge, a le6er from
the Chief Nurse has bee n sent to all Ward Managers, Senior
Nurses and Matrons to emphasise that all s taff are supported to
say no if they feel a paent is not ready to be safely discharged
despite the pressures within the Trust around paent flow. This
Putting Patients First
16
le6er implements the “Safety Pause” which a llows and
encourages clinical s taff to stop and protect me to ensure that
paents are dis charged or transfe rred safely.
Paent Services
The Paent Services team consists of staff handling com plaints,
comments, conce rns and compliments, as well as providing
bereavement services and overseas visitors assessments.
In addion to offering meengs to discuss the outcome of
complaints, more cases are be ing idenfie d as likely to bene fit
from an early meeng, pre-dang a wri6e n re ply. These cases
are picked up at the point of triage and include cases where
there is a re cent bereavement, on-going inpaent ca re,
post-natal issues and complex adm issions.
Feedback also connues to be re ceived via a numbe r of
avenues, including the T rust’s we bsite, paent feedback
websites, the complaints email address and via the PALS team
(Paent Advice and Liais on Service). Feedback consists of not
only complaints but also comments and suggesons, conce rns
and compliments. All feedback is disseminate d to the relevant
staff for their informaon and acon as re quired and is
acknowledged by eithe r the Paent Services team or the Chief
Execuve.
The complaints team connues to be a key part of the Paent
Services Team. In 2012, we increased the number of staff
supporng complaints, and also recruited to a new pos ion of
Complaints Manager. In order to provide a be6er se rvice to
our paents and re laves, the team have relocate d to the ward
block, to place them in an easily accessible locaon. This also
places them closer to the PALS team, which has im proved
communicaon and joint working.
Complaints, Comments and Compliments
In 2012/13 2,505 contacts were handled by the PALS staff and
between 800- 1200 compliments were rece ived during each
Quarter.
Total number of
complaints
Response within 6
months (26 weeks)***
Cases referred to PHSO
For (on-going/further)
local resoluon
No Further Acon – confirmed
Referrals resolved with
intervenon
Referrals accepted for
invesgaon
PHSO referrals upheld
against the Trust
2011/12
2012/13
737
671
99%* (96.8%)**
47
14
91.65%*
(89.12%)**
21
4
24
17
0
0
0
0
1 (2010
invesgaon)
0
* This relates to cases where the first and only response took over 26 weeks.
**This includes cases that received more than o ne response, the final response
being later than 26 weeks.
***The NHS Complaints Regulations 2009, require at section 14 that if a
response is not provided within six months of the date of receipt of a complaint, the Trust must notify the co mplainant i n writing acc ordingly to explain
why and provide a response as soon as reasonably practicable after that time.
An area which has seen a drop in performance is our response
to complaints within 6 m onths. The re a re a numbe r of reasons
why a com plaint may not result in a subs tanve response within six months of receipt, however we recognise tha t we need to
return performance to 2011/12 levels. It is expected tha t in
strengthe ning the team, and the appointment of a Complaints
Manager, we will see the necessary improvements.
In respect of mescales in gene ral, the re needs to be a scale
that allows for prom pt turnaround of straighZorward conce rns
and longe r more detailed invesgaon for complex cases.
Top 3 Complaint Ca tegories
2011/12
Care, monitoring,
review delays
Appointment
problems
Communicaon with
paents/carers
153
126
80
2012/13
Care, monitoring,
review delays
Appointment
problems
Communicaon with
paents/carers
119
105
102
Top 3 Areas for Compla int
2011/12
Outpaents
A&E
Car Park
190
78
25
2012/13
Outpaents
A&E
MEC/MAU
143
66
29
Rao of Complaints to Acvity
Quarter 1
Paent Acvity
Number of Complaints
Rate per 1,000 spells
Quarter 2
Paent Acvity
Number of Complaints
Rate per 1,000 spells
Quarter 3
Paent Acvity
Number of Complaints
Rate per 1,000 spells
Quarter 4
Paent Acvity
Number of Complaints
Rate per 1,000 spells
2011/12*
2012/13
134,099
164
1.22
138,894
173
1.25
138,723
171
1.23
140,694
165
1.17
143,041
200
1.40
141,826
147
1.04
137,808
202
1.47
136,576
186
1.36
*Following a review of the informaon collected and reported in last
year’s Quality Account for this secon, an improved method of data
collecon was idenfied. This new method revised the overall figures
CQC Annual Inpaent Survey
The Annual Inpaent survey (published on the 16th April 2013)
provides some disappoinng res ults for the organisaon.
The Inpaent survey reviewed the expe rience of 850 Individuals
who a6ended for an Inpaent during August 2012.
These survey results need compre hensive cons ideraon to
ensure that im provements are made and that paents re port
those improvements through our monthly paent experie nce
metrics as well as through other paent experie nce feedback
processes.
The results need conside raon alongside our ope raonal
performance and capacity acon plans, as many of the areas
demonstra te the impact that the flow of paents though our
hospitals is having on the paents wa ing within A&E and
awaing a bed. However, the core of this s urvey is about our
support and communicaon with paents which we need to
review and be clear about how we will improve.
Overall the paent experience survey demonstrates that the
trust has scored poorly in com parison the previous year’s
results in the following secons
Putting Patients First
17
•
The Emergency Department
•
Doctors
•
Leaving hospital
•
Overall experience
Within the other six secons we score d about the same as the
other trusts. In no secon did the trus t pe rform be 6er than the
other trusts.
Following the publicaon of the 2011 s urvey, the corporate
nursing team working with the bed holding clinical ce ntres
developed an acon plan to address the areas highlighted for
improvement.
Key areas idenfied previous ly
•
Wait me in A&E depa rtment
•
Access to the waing list
•
Paent experience on the ward
•
Informaon given to paents
•
Leaving the hos pital and the dis charge process
The 2012 survey has highlighted sim ilar areas for im provement
and demonstrates the need for a different approach to
improvements and also a review of this feedback in conjuncon
with the s taff survey res ults and the operaonal performance
with paent flow and parcularly the consis tently highlighted
area of expe rience with paent discha rge, hence why this is a
priority for the year ahead.
The results of the survey are currently being disseminated to
the clinical centres and our Paent Expe rience and Involvement
Panel. Acons are being idenfied and will form pa rt of the
plans for 2013/14.
Paent Flow – Right Paent, Right Place
Right Paent, Right Place is the num ber one priority for the
Trust as ge;ng this right for paents has a posive impact
across a broad range of quality and expe rience indicators.
Increased levels of A&E a6enda nces have put significant
pressure on the hospitals, which has s omemes resulted in
longer than e xpecte d waits in A&E, delays in paent flow and
cancelled ope raons. This has also been exacerbated by delays
in discharging paents with com plex care needs a nd we have
been working with the local health and social ca re economy to
make improvements across this issue.
The key issues we face are managing the volume of eme rgency
admissions, discharging those paents who need addional
support to leave hospital in a mely fashion and ensuring that
we do not cancel operaons unnecessarily.
At the Trust a group of senior doctors, nurses and managers
have met to get a be6e r unde rstanding of the difficules we
have faced in ge;ng planned surgical paents in to hospital
during the winte r while managing the overa ll increase in
demand for emergency care. It was acknowledged that the
Trust did not have enough beds to ma nage both eme rgency
and elecve demand. We then developed a number of ideas
that would help to release acute hos pital be ds for acutely ill
paents.
•
Ulising beds in the comm unity for paents waing for
their packages of care or for their home of choice to
become available
•
Connuing to monitor the numbe r of ‘Fit for Discharge’
paents and work with others to reduce.
•
Ensuring elecve day case medical paents do not come
into inpaent beds, but are place d in day case beds
instead
•
Changing the use of Day Surgery to provide short stay
surgery beds
•
Swapping the locaons of AMU and SAU at RSH to
improve the configuraon of these services.
•
Making Ward 22E at RSH and Wa rd 12 at PRH
permanent wards rather than escalaon areas to
increase the Trust’s permane nt be d capacity
•
Establish a Clinical Decis ion Unit at the Royal
Shrewsbury Hospital to manage paents who do not
need to be admi6e d to hospital, but sll need further
invesgaon before being discha rged
•
Improving discha rge skills and compe tencies to support
mely discharge
In the com ing year, we will connue to review and assess the
benefit of the cha nges tha t have been ma de, and strive to
make further improvements to paent flow. The Trust
connues to adapt its services and configuraon in orde r to
meet the needs of our paents through the on-going Future
Configuraon of Hospital Services plan.
Reconfiguraon of Services
Our goal in 2012/13 was to ensure we gained the final stage of
approval and funding for our plans to keep services in the
county. This was achieved with the formal approval of our Full
Business Case for the Future Configuraon of Hospita l Services
by the then eme rging Clinical Commissioning Groups, the PCT
Cluste r and NHS Midlands and East.
Key to this approval was the connued involvement and
engagement of clinicians, staff and managers in the development of the new mode ls of ca res, paent pathways, workforce
models and new ways of working as well as the design and
development of the new fa cilies at both sites.
Putting Patients First
18
Progression of plans to refurbish areas at both s ites
On achieving this goal, our aim of consolidang Surgery at •
associated with the move of Wome n and Children’s
Shrewsbury ahead of our original mescales could be
Services
implemente d and in order to maintain the ‘balance’ betwee n
In
the
coming months, we will connue to progress the
our hos pital sites we were also able to accelera te the move of
implementaon
of the changes to Wome n and Childre n’s
Head and Neck Services to Telford.
Services. This will include:
Our goal and comm itment of involving, engaging and informDetailed ope raonal planning within Women a nd
ing our paents, their families and the public on the changes •
Children’s Services and across the T rust to deliver a
to our hospital services connued in 2012-2013 and include d
reconfigured service including de livery of our workforce
Focus Groups, a6endance at comm unity groups, newsle 6ers,
and training plans
adverts in the local press and radio and television interviews.
•
Ongoing engagement and involvement with staff, paents
In 2012-13 we achieved:
and the public in all areas of change from paent
pathways and public informaon to the design of new
•
Final approval of ne w mode ls of care, paents pathways
paent areas and a rtwork
and new ways of working within Surgery, Head and
•
Building works at both sites to create the new facilies
Neck and Women and Children’s Services
associated with the planned changes
•
Approval and funding of the Full Bus iness Case for the
•
Providing deta iled upda tes to the Joint HOSC and CCGs as
Future Configuraon of Hospital Services
part of the ongoing assurance process
•
The cons olidaon of Surge ry at RSH and Head and Neck
•
Developing and progressing ideas to help current and exat PRH
staff alongside our paents and their families celebrate
•
The creaon of a new Surgica l Assessment Unit and
the old service and building and welcome the new
Surgical Short Stay facility at RSH
•
•
•
•
•
The development of new outpaent and inpaent Head
and Neck facilies at PRH, with improved new en-suite
facilies for paents with cancer
Enabling works at PRH to make way for the construcon
of the new W omen and Children’s Unit – this involved
moving and relocang Medical Records, Hospedia and
Children’s Outpaents as well as the He lipad a short
distance
A new car park at PRH, increasing car pa rking spaces at
the site and returning the main front ca r park to
paents and visitors only
The start of the cons trucon of the new Women and
Children’s Unit which will connue unl May 2014
Progression of the plans for the new facilies at RSH
including a new Women’s Zone (to include a new Midwife Le d Unit, Maternity Outpaents and Scan,
Antenatal Day Assessment and Early Pregnancy Assessment) and a new Childrens’ Zone (to include a new
Children’s Assessment Unit and Children’s Outpaents)
Educaon and Learning
A Fundamentals of Care training day is being launche d this year
for all ward based regis tered nurses in orde r to ensure that we
deliver focused educaon on the direct ca re issues that really
ma6er to our paents and staff. Staff have fed back to us that
they would find this training highly valuable and we have made
every effort to e nsure tha t it is interacve, inte resng and above
all relevant to clinical pracse.
The day will feature a video of examples of good and poor pracce which nurses are then required to crique us ing the 6C’s
methodology. We look forward to feeding back on the success
of this new training in next year’s Quality Account.
Staff at all levels and in all roles, clinical and non-clinical, need to
be skilled, knowledgeable and up to date about the most
effecve ways of caring for our paents. Educaon and lea rning
is a valued and key acvity in the organisaon as a way of
supporng staff to improve the quality of the service they
deliver and the outcomes for paents.
Putting Patients First
19
During 2012-13 we:
•
•
supported 161 staff to complete vocaonal qualificaons in subjects such as Care, Physiothe rapy
and Occupaonal Therapy support, Business and
Administraon
Support a second cohort of staff to achieve an accredite d
coaching qualificaon that results in hones t, open,
respecZul and cha llenging conversaons which support
personal accountability
Workforce
increased our focus on leade rship and management
development with over 182 places be ing taken up on
leadership training programmes or accredited courses of
study
•
enabled over 100 staff to take up coaching support from
an accredited coach
•
extended the educaon services available to staff to
ensure evidence based pracce
•
reviewed our pe rsonal and paent safety re lated
training and put an improvement plan into place
•
enabled over 80% of staff to take up lea rning
opportunies
During 2013-14 we will:
•
•
•
•
•
•
•
Review and further increase our leade rship development acvity to recognise that high quality leaders hip
needs to be supported at all levels of the organisaon
Introduce a mandatory Essenals of Ca re programme
for all nursing staff
Increase the take up of e-learning to enable staff to
make the most of this resource
Work with managers to ensure that they are able to
access mely data to ensure their s taff have undertaken
all require d learning
Hold a second SaTH Leaders hip Confe rence available to
all staff which showcases best pra cce and evidence based leadership
Improve our Appraisal process to ens ure that it re flects
Trust Values
2012 and early 2013 saw us change our approach to Workforce,
with very posive results:
Through the Leade rship Academy over 40 people have
undertaken Leadership Developme nt thanks to our partnership
with Warwick University.
• We have developed an Apprenceship programme
allowing individuals to unde rtake work-based training
programmes throughout the organisaon.
• Working with the Princes Trust we have introduce d a work
experie nce programme that engages young people in caree rs in
the NHS.
• We have 15 inte rnal qualified coaches, providing support to
a range of staff and a further cohort of coaches are due to
conclude their tra ining in 2013.
• We have focused efforts on promong Health and
Wellbeing — we held Health and Wellbe ing Roadshows, Zumba
classes and launched the A Healthier You intranet pages. To
support managers we have appointe d a Wellbe ing and
A6endance Advisor.
We held our firs t Leadership Confe rence which nearly 200
people a6e nded.
•
Looking to the year ahead it is important that we focus on
building on these achievements to e nsure that as an employer
we are providing a posive expe rience for staff ensuring that
staff are proud to work with us. This will be achieved through
Putting Patients First
20
supporng staff in their roles to deliver or support the delivery
of excellent paent care im proving the paent e xperience. In
2012 the Staff Survey was sent to all s taff and we saw a 57%
response rate — a total of 2,910 individuals.
The results for Staff Engagement demons trate that overall our
scores are worse than the naonal average; however within
this the numbe r of staff reporng that they are able to
contribute towards improvements at work has increased from
53% in 2011 to 60% in 2013. Other a reas of improvement
include Staff Job Sasfacon and the number of staff re ceiving
appraisals.
However the re remain key areas of focus for the T rust
Place s taff want to work and recommend for treatment – in
2011 the Trus t score for this finding was 3.31 (out of 5) but has
fallen this year to 3.27 whils t the naonal average for acute
Trust is 3.57.
Develop a nd enhanced Lea dership in line with Trust values –
as above the number of staff stang that they are able to
contribute towa rds at work has increased (although the
naonal average is 68%. Unfortunate ly the pe rcentage of staff
reporng good communicaon between senior management
and staff (19%) is significantly less than the naonal average
(27%).
Health and Wellbeing of all staff is a priority – 30% of staff
report that they believe the organisaon takes posive acon
on health and well being compared to the naonal average of
43%.
Having taken the opportunity to survey the whole workforce in
2012 the detailed res ponses have allowed us to review results
by individual Care Group and Centre. Each Centre has
idenfied their top three areas for acon in addion to the
Trusts key areas above to target and focus developments and
enhancements to s taff needs.
During 2013 we have an ambious agenda including:
• Further Leaders hip and Management Development
• Organisaonal refocus to support the development of Ca re
Groups and ensure that our Workforce Directorate is
appropriate a ligned to support these teams.
• Expansion of our Staff E ngagement mode l to ensure that
staff are involved in decisions and communicated with
effecvely.
• A new recruitme nt process to ensure we have the right
person in post at the right me.
• Further tra ining opportunies available on E -Learning.
• Implemenng an electronic bank staff system to support
our temporary staffing needs.
• More Health and Wellbeing Roadshows.
• A second Leade rship Developme nt Confe rence.
Understanding culture and learning from the
Francis Report
Culture
It is so important that we ensure tha t all staff across the Trus t
believe in and live to our Trust values. We plan to review our
Trust values this year to e nsure that they are up to date and
meaningful. We will the n support a nd e ngage with our staff to
help them to input to and unde rstand these values which will
drive everything we do.
To ensure these values a re embe dded for the future we will be
developing a values based re cruitment process in order to
ensure tha t we recruit the “right person” to our roles. For
nursing posts this will e ncompass the 6 C’s approach as laid out
by Jane Cummins, Chief Nursing Officer for England.
The Francis Report
In 2011 the Board conside red the key themes and acons
arising from a series of naonal reports (including the firs t
Francis report) and the recommendaons aris ing from these
and in January 2013 updated this to include The Winterbourne
view report.
In 2012/13 the re have been some key changes in Chief
Execuve and Execuve Director roles and to support the
review of the F rancis report (2013) and the emerging response
and recommendaons by the Department of Health, the
previous Board paper has been updated again to provide a
high level overview of how we will as an organisaon progress
the key themes of the Francis Report.
The Statement of common purpose reflected in the
Department of Health response to the Francis report is one
that is core to the principles of the NHS Constuon. The
Quality and Safety Commi6ee have signed up to this statement
and formally have asked the Board to do the same which
responds to the DH request to s ign up to the Sta tement of
common purpose.
The Quality and Safety Commi6ee will connue to monitor
overall progress against re commendaons and provide an
overview to the Board on a six m onthly basis, with an inial
report be ing made by the Commi6ee in May 2013.
Putting Patients First
21
1.4
Looking Ahead
By email to consultaon@sath.nhs.uk – please put “Quality
Account” as the subje ct of your email
Our fourth Quality Account aims to be honest and open with
our performance over the last year and encourage scruny of
the improvements we have made and those that we mus t
achieve in the year ahead.
Our work with the local health and social care economy
towards improving the flow of paents through our hospitals is
starng to demonstrate improvements. However, we must
connue to focus our efforts in this area and on the priories
we have set ourselves to ensure we achieve these key
improvements.
Developing our Quality Accounts is always an ongoing valuable
learning experie nce for the Trust and we view each year’s
account as an opportunity to improve and inform our
stakeholders and the public about the quality of care and
services we provide. Last year, our s takeholde rs told us that we
had improved on the previous year in terms of presentaon
and accessibility and they would like to see us m ove more in
this direcon in 2012/13. We have responded to this by
including more visual informaon and grouping it into secons
to make it easie r to read and understand. We will endeavour
to furthe r develop the accounts year on year, and we acvely
encourage your feedback. Please let us know your views, to
help us e nhance paent expe rience, safety and effecveness.
By fax to 01743 261489 – please put “Quality Account” as the
subject of your fax
By post to Quality Account, c/o Chief Nurse/Director of Quality
& Safety, The Shrewsbury and Telford Hospital NHS T rust, Royal
Shrewsbury Hospita l, My6on Oak Road, Shrewsbury SY3 8XQ
We welcome your feedback on any aspect of this docume nt, but
specific quesons you may wis h to consider include:
•
What do you think are our biggest opportunies for
making progress on the Quality Priories listed in Secon
1.2?
•
What acons should we be taking to improve quality in
these areas?
•
How should we involve paents and communies in our
work to improve the quality of the services we provide?
•
Do you have any comments or suggesons on the format
of our Quality Account?
•
What else would like to see in our qua lity accounts?
Looking furthe r ahead, we welcome your suggesons for our
Quality Priories in 2014/15 – we will select three to six top
priority issues across the three dimensions of quality (paent
experie nce, safety, effecveness).
Your Feedback Counts
We welcome your feedback on our Quality Account. You can
let us know in a variety of ways:
Putting Patients First
22
Putting Patients First
Part 2
Statutory Requirements
23
2.1
No.
Key Performance Indicators reported and monitored by the Shre wsbury and Telford Hospita l NHS T rust based on naonal and local priories. The table below reports performance against these and against the previous year, with naonal informaon whe re it is a mandatory requirement*.
Des cription of Ta rget
2011/12
2012/13
National
Average
Trust
Target
2
1
-
2
41
45
-
45
Patient Safety Measures
1
MRSA Bacteraemia (bloods tream) infections
2
Clostridium difficile infections
3
Clostridium difficile infections pe r 100,000 bed days*
-
11.86
6.52
-
4
Rate Surgical Site Infections per 10,000 Orthopaedic ope rations*
-
66.9
88.2
-
5
MRSA Screening Emergency Admissions
96%
92.82%
-
95%
6
MRSA Screening Elective Admissions
91%
93.35%
-
95%
7
Hand Hygiene
98%
99%
-
95%
8
Percentage of admitted patients risk assessed for Venous Thromboembolism (VTE)*
91.48%
90.08%
93.7%
90%
9
Reducing inpa tient falls
1590
1538
-
-
10
Safe Surgery checklist compliance
99%
99.96%
-
100%
11
Rate of patient safety incidents pe r 100 adm issions
6.66
6.85
6.81
-
12
Rate of ‘serious harm’ patient safety incidents re ported per 100 admissions*
-
0.62
0.41
-
13
Number of patient safety incidents reported**
7800
7599
-
-
14
Number of patient safety incidents resulting in severe harm/death**
40
89
-
-
15
Percentage of patie nt safety incide nts resulting in severe harm or death as a percentage of the num ber of patient safety incidents
0.51%
1.17%
0.7%
-
16
Avoiding preventable pressure ulce rs (grade 3 & 4)
20
42
-
-
-
105.3
100
-
Clinica l Outcome Measures
17
Standard Hospital Mortality Indica tor (SHMI)* (lower is better)
18
Percentage of palliative care deaths which is coded appropriately (at e ithe r diagnosis or s pecialty level)
17.36%
17.02%
-
-
19
2 week wait for cancer referrals
97.86%
96.00%
-
93%
20
18 week GP referral to first treatment - Admitted
94.48%
78.00%
-
90%
21
18 week GP referral to first treatment - Non Adm itte d
87.31%
95.08%
-
95%
22
Patient Reported Outcome Measure - groin hernia surge ry*
-
39.4%
51.6%
-
23
Patient Reported Outcome Measure - varicose vein surgery*
-
56.3%
51.6%
-
24
Patient Reported Outcome Measure - hip replacement surgery*
-
100%
88.4%
-
25
Patient Reported Outcome Measure - knee replacement surgery*
-
66.7%
78.9%
-
26
Percentage or pa tients aged 0 - 14 readmitted within 28 days of discharge
9.3%
9.9%
-
-
27
Percentage or pa tients aged 15+ rea dmitte d within 28 days of dis charge
5.4%
5.4%
-
-
94.52%
90.62%
-
95%
64.3
62.1
68.1
Maintain
or improve
-
50.9%
62.8%
-
Patient Experience Measures
28
A&E 4 hour wait
29
Responsiveness to inpatients pe rsonal needs (maintain or improve) - CQUIN Score
out of 100
30
Staff survey - Perce ntage of s taff who would recommend the Trus t to friends or
family needing ca re
- Data is not requir ed or is not av ailab le
** Oct 10 - Oct 11 & Oct 11 - Oct 12
*source—Methods Insight quart erly Acute Trust Quality Dashboard
Putting Patients First
24
2.2
Statements of Assurance
Progress and achievement of this year’s quality
priories will be reported to the Quality and Safety Commi6ee
which is a formal s ubcomm i6ee of the board, exte rnally to
commissioning groups via the Commissioning Quality Review
meeng and in the 2013/14 quality account
•
Daycases
•
Elecve care
•
Emergency care, including A&E services
•
Maternity care
•
Outpaents
During 2012/13 the Shrews bury and Telford Hospital NHS Trus t
How will we monitor, measure and report progress provided and/or subcontracte d the full range of se rvices for
which it is regis tered NHS Services (these are detaile d in the
to improve quality, including our Quality Priories?
Trust’s Annual Report 2012/13 or via our we b site).
Paent Experience
The Trust supported a num ber of reviews of its services during
Our improvements against the priories will be monitored by 2012 and 2013. These were undertaken by externa l
our Paent Expe rience and Involvement Pane l who will receive organisaons and included:
reports on progress and results of paent e xperience surveys
• The Care Quality Commission
and audits throughout the year. The Quality and Safety
• Annual Cancer Peer review
Commi6ee will rece ive a summary of progress and will hold us
• Royal College of Ophthalmology: Cataract pathway
to account for delivery of the priories relang to paent
review
experie nce.
• Ofsted/CQC review of children’s safeguarding services
Our performance against measuring and im proving paent
experie nce will als o be reporte d to our commissione rs through The Trust did not formally review any of its own se rvices
the Comm issioning Quality Review meeng on a monthly basis.
however, did review and support individual wa rds on a quality
improvement framework, reviewed paent flow processes and
Paent Safety
supported the Royal College of Opthalmology review by sharing
Our 2 key safety priories of pressure ulcer elim inaon and falls trust invesgaon findings. The Trust has reviewed all of the
reducon will be monitored by the spe cific task group for each informaon available in relaon to the se rvices provided.
which will also support the de livery of the work that needs to be
done. These and a range of safety metrics are presented and
discussed by clinical centre senior nurses at the Nursing and
Midwifery Forum where pee r and corporate challenge is given
and acons for improvement agreed. The Quality and Safety
Commi6ee will receive informaon regarding to pe rforma nce
and progress in the monthly quality report. The quality re port
contains a variety of me trics relang to paent safety which a re
carefully monitored and cha llenged by the commi6ee who
conduct a visit to a clinical area to gain furthe r assurance on a
monthly basis.
Our quality report is also sha red with
commissioning groups and forms the basis of discussion at the
Commissioning Quality Review meeng.
Clinica l effecveness a nd outcomes
We recognise that the priority to improve discharge really
ma6ers to paents and their relaves or ca rers. We will
monitor our prog ress in this area closely and ensure that we
foster a partne rship working approach to ensure that we make
improvements in this a rea. Reporng against our pe rforma nce
in this area will be at many levels throughout the Trust from
Ward to Board level and externally to the Trus t through
commissione rs and othe r stakeholders.
Progress and outcomes of clinica l audit connue to be share d
across the T rust and compliance with NICE guidelines and
Technology Appraisals (TAG) is re ported both inte rnally and
externally to commissioning g roups.
Review of Services
The categories of services provided by The Shrewsbury and
Telford Hospital NHS Trus t are:
Putting Patients First
25
The following inte rnal and exte rnal reviews tool place during 2012—2013
Unannounced ins pecons were carried out on the Princess Royal
Hospital site in May 2012 a nd at the Royal Shre wsbury Hospital site in
August 2012. Reasons for the visits were; Princess Royal Hos pital—part
of the CQC roune schedule of planned reviews. Royal Shrewsbury
Hospital—part of a follow up schedule of visits to the previous Dignity
Trust Wide Inspecons
and Nutrion scheme comm issioned by the Secre tary of Sta te. Both
CQC
visits concluded that there we re no longe r any concerns regarding the
care delivered against the assessed standards and all previous concerns
were liSed. However, a further unannounced visit was carried out at the
Princess Royal Hos pital in April 2013 and the T rust is awaing the formal
report in re laon to this.
Trust Wide NPSA PEAT
Formal annual assessment undertaken across both s ites with a n outcome
Assessment
of “exce llent” rang
The departme nt maintained its external audit success and compliance
Medical Engineering Services
with the requirements of ISO 9001:2008 and on-going ISO 13485:2008
Our pharmacy de partment was subject to a roune review by the Brish
Pharmaceucal Society of Great Britain. The outcome of the review was
Trust Wide Pha rmacy
that the se rvices provided we re sasfactory and no conce rns were raised
regarding the outcome of the visit.
Assurance Visit (undertaken by Commissioners) took place in Janua ry
2012 with a parcular focus on clinical governance arra ngements,
Maternity
process for unde rtaking root cause analysis following serious
incide nts. The Trust received posive feedback.
Midwifery services a re reviewe d annually by the Wes t Midlands Local
Supervising Authority Maternity Officer (WM LSAMO) to ensure that the
arrangements for and the execuon of Supervision of Midwives are
Midwifery
sasfactory. The Trust again received posive feedback highlighng the
proacve approach to supe rvision within SaTH. SaTH will be e xploring
how to meet the recommended rao of 1 Supervisor of Midwives to 15
pracsing midwives.
A Peer Review was undertaken in August 2012. SaTH scored 94.2% for
Paediatric Oncology
core measures and 94.7% for MDT measures.
A Peer Review was undertaken during 2012/13. Informaon for childre n,
young people and their families was good. The informaon was
Paediatric Diabec
comprehe nsive, clear and well-presented. No immediate risks were
idenfied
A Peer Review was undertaken in March 2013. A number of areas of
Paediatric Cysc Fibrosis
good pracce idenfied as well as a 1 area for development.
A Peer Review was undertaken during 2012/13. A number of significant
Gynaecology Oncology
achievements idenfied. No imme diate risks or serious conce rns ra ised,
with a small num ber of areas for development idenfied.
A HFEA visit was unde rtaken during 2012/13 with a full review scheduled
Ferlity
for May 2013
There was a RSH Blood T ransfusion laboratory inspe con by the MHRA
following the annual self-assessment return. The inspector was sasfied
Laboratory Services
that the depa rtment was fully compliant with the Blood Safety and
Quality Regulaons 2005.
Royal College of Ophthalmology visit – 17th September 2012 – review
Cataract pathway, procedures and processes by exte rnal clinical advisory
Ophthalmology
team following series of Never Events being reported. Very posive
report highlighng improvements ma de and a reas of good pracce
NHS Bowe l Cance r Scree ning Programme (BCSP) Regional Quality
Assurance visit Shrops hire Bowel Cancer Scree ning Centre underwent its
first 3 yearly visit. The purpose was to e xamine the performance of all
NHS Bowe l Cancer Screening
aspects of the programme at scree ning ce ntre and professional level as
Programme (BCSP) Regional
well as verificaon of achievement of naonal BCSP standards. All
Quality Assurance visit
stakeholders involved with the se rvice we re reviewed. Excellent feedback
overall with 13 points of good pracce idenfied. The main
recommendaons focussed on elements to e nable the implementaon
of the age extension.
Putting Patients First
26
WHO Safe Surgery Checklist
Telford & Wrekin Ofsted
Inspecon for Safeguarding
Children
Cancer Centre Quality
Management System
2012/13 Annual Cancer Peer
Review
Environmental Health Food
Hygiene Inspecon
Cleanliness and Paent
Environment Audits
Quality & Safety Commi6ee
As part of the World Hea lth O rganisaon drive and in response to the Who
Surgical Safety Che cklist, theatres within SaTH unde rtake a m onthly audit
assessing theatre staff compliance for compleng the Who Safer Surgery
Checklist. This audit is undertaken in each thea tre, 19 in total and includes a
minimum of 10 paents per theatre per month. The audit is very specific and
looks at staff undertaking the following tasks, prior to each paents
operaon:
• Team Brief
• Time Out
• Sign Out
The Trust consis tently achieves 100% compliance with this audit.
As part of this inspecon the CQC visited the Eme rgency Department at PRH
and Wrekin Maternity In June 2012. Issues reported were inadequate
safeguarding supe rvision for Eme rgency Ca re staff a nd reassurance that
medical s taff were all compleng Safeguarding training. This has bee n
addressed by ensuring that Safeguarding Supervision is in place for 2013 and
all medical staff have been e ncouraged to unde rtake online safeguarding
training.
The Radiothera py Departme nt has had BSI ISO 9000 cerficaon s ince 1999
however this has been extended to include Chem othe rapy. The
Chemothe rapy and Ra diotherapy se rvices were jointly cerfica ted for ISO
9001:2008 in March 2012 and since then have had two further BSI
assessment visits. The Jan 2013 visit offered parcularly posive commentary
and closed two m inor non conform ies so the re are now no exisng non
conformies within the Centre. A compre hensive inte rnal audit schedule is
maintained as per BSI framework and results fed in to appropriate
governance groups/sub groups for acons and quarte rly reports provided for
the SaTH clinical audit department. Off procedure events are reported/
aconed via the Quality Management System, thus maintaining an open and
transpare nt system of clinical work. Work has now begun to construct a QMS
for haematology with a view to BSI cerficaon in 2014.
3 clinical teams have unde rgone exte rnal review in March 2013 as part of the
Peer Review cycle of 2012/13. The final reports from which will follow on
thereaSer. 9 clinical teams unde rwent self assessment and 8 clinical teams
underwe nt self assessment and internal validaon. There were a cons iderable
number of examples of good pracce and s ignificant achievements noted in
the reports. These included recognion about recruing into key vacant
posts, ISO accreditaon for the Oncology Chemothera py service, undertaking
audits, pa rcipang in clinical trials, improved data colle con, developing
new services e.g. one-stop and fast track clinics, improved paent outcomes
and exce llent paent informaon. The re was only 1 se rious concern noted by
the Breast team in re laon to the re configuraon of the middle g rade
posion as failure to re place these posts would restrict the ability of the
Consultants to deliver an effecve service. All conce rns and serious concerns
were discussed with the re levant Centre Chiefs and Centre Managers for their
conside raon and acon. The serious conce rn was escalated to Execuve
level. A new process of raficaon, comm unicaon and escalaon was
implemente d for this cycle of Pee r Review.
The Cance r Value Stream meets with the clinical teams qua rte rly to dis cuss
their Peer Review compliance and cancer target performance.
Environmental Hea lth Inspecons were carried out for both sites. We
achieved a score of ‘4’ for our Food Hygiene rang at the Royal Shrewsbury
Hospital and ‘5’ at the Princess Royal Hos pital.
Review of cleanliness assessed against the Naonal Standards of Cleanliness
carrie d out monthly
Internal Paent Environment audits a re carried out monthly
Connue to s upport and receive fee dback from quality and safety walkabouts
and to receive and gain assurance re lang to qua lity improvement
frameworks.
Putting Patients First
27
2.3
Parcipaon in Clinical Audit
This secon of our Qua lity Account provides
informaon about our pa rcipaon in clinical audit.
Clinical audit is “a quality improvement process that seeks to
improve paent ca re and outcomes through systemac review of
care against explicit criteria and the implementaon of change.
Aspects of the structure, processes, and outcomes of care are
selected and systemacally evaluated against explicit criteria.
Where indica ted, changes are implemented at an individual,
team, or service level and further monitoring is used to confirm
improvement in healthcare delivery.” Parcipaon in naonal
clinical audits, naonal confidenal enquiries and local clinical
audits provide an im portant opportunity to smulate quality
improvement within individua l organisaons and across the NHS
as a whole.
Secon 2.4
The naonal clinical audits and naonal confidenal enquiries
that the Shrewsbury and Telford Hospital NHS T rust
parcipated in, and for which data collecon was completed
during 1st April 2012 and 31 st March 2013 alongside the number of cases submi6ed to each audit or e nquiry as a percentage of the number of registe red cases require d by the terms
of that audit or enquiry are liste d at:
h6p://www.sath.nhs.uk/Library/Docume nts/Clinical_Audit/
QA%202012%2013%20TABLE%203.pdf
Secon 2.5
The reports of [5] naonal audits we re reviewed by the
provide r during 1 st April 2012 and 31 st March 2013.
Secon 2.6
The Shrewsbury and Telford Hospital NHS T rust intends to
Clini cal Audi ts
take the acons liste d to improve the quality of healthcare
Secon 2
provided:
During 1 st April 2012 to 31 st March 2013, 68 naonal clinical h6p://www.sath.nhs.uk/Library/Docume nts/Clinical_Audit/
audits and 5 Naonal Confidenal Enquiries (NCEPOD) covered QA%202012%2013%20TABLE%204.pdf
NHS services that the Shrewsbury and Telford Hospital NHS Trust
provides.
Secon 2.1
During that pe riod the Shrewsbury and Telford Hospita l NHS
Trust pa rcipated in 63 / 68 [93%] of the naonal clinical audits
and 5/5 [100%] naonal confidenal enquiries which it was
eligible to pa rcipate in.
Secon 2.2
The naonal clinical audits and naonal confidenal enquiries
that the Shrewsbury and Telford Hospital NHS Trus t was eligible
to parcipate in during 1 st April 2012 to 31 st March 2013 [73] are
listed at
h6p://www.sath.nhs.uk/Library/Docume nts/Clinical_Audit/QA%
202012%2013%20TABLE%201.pdf
Secon 2.7
The reports of [93] local clinical audits we re reviewe d by the
provide r during 1 st April 2012 and 31 st March 2013
Secon 2.8
The acons which the Shrewsbury and Telford Hospital NHS
Trust inte nds to take the following acons to improve the
quality of healthcare provide d are listed at:
h6p://www.sath.nhs.uk/Library/Docume nts/Clinical_Audit/
QA%202012%2013%20TABLE%205.pdf
Brief highlights include:
•
Nursing documentaon reviewed and implemented
•
Radiographers training prog ramme devised to ens ure
competency standards
Secon 2.3
•
The naonal clinical audits and naonal confidenal enquiries
that the Shrewsbury and Telford Hos pital NHS Trus t parcipated
in between April 2012 and 31st March 2013 are listed at:
h6p://www.sath.nhs.uk/Library/Docume nts/Clinical_Audit/QA% •
202012%2013%20TABLE%202.pdf
Role of Designated Professionals for safeguarding
children and young people included in training
presentaons
A new chest pa in pathway has been introduced to
enhance the treatment of these paents
Putting Patients First
28
care.
Acve parcipaon in clinical research demonstrates The
Research is a core pa rt of the NHS, enabling the Shrewsbury and Telford Hospital NHS Trus t’s commitment to
NHS to improve the curre nt and future health of improving the quality of care we offe r and to making our
the people we serve.
contribuon to wide r health improvement.
What have we done?
The Shrewsbury and Telford Hospital NHS T rust works closely
with the West Midlands North CLRN (Comprehens ive Local
Research Network) and the Topic Specific Networks to prom ote a
robus t research culture. We connue to be acve offering
paents opportunies to parcipate in studies in a wide varie ty
of speciales. Overall recruitme nt is slightly lowe r than 2011/12
as a result of the naonal closure of several large cancer genecs
studies which reached their required numbers.
We have improved our Trust approval process so that by the
second half of 2012/13 all new studies com plete d the process
within 30 days.
Processes have been put in place to facilitate recruing the first
paent within 30 days of ope ning a new study and work
connues to improve on this.
Work has starte d on increasing e ngagement at all levels within
the T rust and the public by promoonal events, acvity report to
the Board and appointment of 2 lay membe rs to the R&D
Commi6ee.
The numbe r of paents re ceiving NHS services provided or subcontracted by The Shre wsbury and Telford Hospital NHS T rust in
2012/13 that were recruited during that pe riod to parcipa te in
research approved by a research ethics commi6ee was 1273
Recruitment
2012/13
Total no of
studies
2012/13
Recruitment
2011/12
Total no of s tudies
2011/12
Specialty
Cancer
Cardiovascular
Gastro-Intesnal
Stroke
33
2
14
3
624
47
467
62
24
3
16
2
301
137
443
32
Respiratory
Reproducve
Health
Medicines for
Children (inc non
drug studies)
Renal
Surgical
Demena
Dermatology
Other
Totals
3
3
19
10
1
3
1
30
5
16
5
63
4
2
1
1
1
71
16
7
62
4
54
1389
1
1
4
60
23
6
189
6
42
1273
The Shrewsbury and Telford Hospital NHS Trust employs 25
dedicated research nurses, allie d health professionals,
assistant resea rch praconers, da ta and adm inis trave staff
supporng
the 32 Principle Invesgators and many
co-invesgators.
What we will do in the coming year?
Meet naonal ta rget for study approval process me
lines of > 80% gaining local approval within 30 days.
Work towa rds > 80% of studies whe re annual
recruitment target is 12 or m ore recruing first paent
within 30 days of approval.
Support local Principle Invesgators in becom ing Chief
Invesgators for 2 or more mulcentre studies
Increase the numbe r of commercial studies recruing
during the year from 7 in 2012/13 to10 in 2013/14
Open drug s tudies in haematological cancer and in
emergency medicine.
Increase engagement at all levels to promote research
acvity within the T rust
•
•
•
•
•
•
2.5
Data Quality
This secon of our Quality Account provides
informaon about data quality. Good quality
informaon unde rpins the delivery of effecve paent care
and is essenal if im provements in quality of care are to be
made.
During the reporng pe riod April 2012 to March 2013, the
Trust s ubmi6e d records to the Secondary Uses Service (SUS)
for inclus ion in the Hospital Episode Stascs.
The perce ntage of records in the published data (based on
April-Jan 12/13) SUS data at the m onth 10 inclus ion date)
which included the paent’s valid NHS number was:
Valid NHS Number
% Valid
2.4
Parcipaon in Clinical Research
101 .00%
100 .00%
9 9.00%
9 8.00%
9 7.00%
9 6.00%
9 5.00%
9 4.00%
9 3.00%
9 2.00%
National
Provider
Inpatients
Outpatient
A&E
Ac ti vi ty
Which included the paent’s valid Gene ral Medica l Pracce
Code was:
Valid General Medic al Practice Code
Where trials are adopted by more than 1 specialty they have been
assigned to the specialty of the Principle Invesgator
100 .1 0%
100 .0 0%
A full list of re cruing studies is available from the T rust:
research@sath.nhs.uk
The Shrewsbury and Telford Hospital NHS Trust also acts as a
Connuing Ca re site for local childre n recruite d into ca ncer
studies a t Birm ingham, delivering all the treatment and follow up
% Valid
99 .90%
N ational
99 .80%
P rovid er
99 .70%
99 .60%
99 .50%
Putting Patients First
Inpatients
Outpatient
A& E
A c tivi ty
29
2013 will see s ome furthe r investment in the Data Quality Team to
connue with the exisng prog ramme of work. T here have
already been s ignificant improvements in some key areas for
example duplicate registraons have been reduced by 75%. All
front line service areas have received training on how to validate
paent demographics using the naonal spine, for data collecon
requirements.
Data Quality: Clinical Coding
The Shrewsbury and Te lford Hospitals was subject to the Payment
by Results clinical coding audit during the re porng pe riod April
2012 to March 2013 by the Audit Commission and the e rror rates
reported in the latest published audit for that pe riod for diagnosis
and trea tment coding (clinical coding) were:
Primary Diagnos is incorrect
4.5%
Secondary Diagnosis incorrect
11.4%
Primary Procedure incorre ct
14.3%
Secondary Procedure incorrect
4.1%
The performance of the Trust, measured against the num ber of
spells with an incorrect payment, places the trus t be6e r than
average, compared to last year’s naonal pe rformance.
achieve to ensure it fulfils its obligaons to ensure that
informaon about paents and staff is handle d legally,
securely, efficie ntly and effecvely. The purpose of the
assessment is to e nable organisaons to measure their
compliance against the law and central guidance and to
provide assurance to its stakeholde rs. This in-turn increases
public confide nce that ‘the NHS’ and its partners can be
truste d with pe rsonal data.
The curre nt assessment has been submi6ed for March 31st
2013. The Trust has achieved a ‘sasfactory’ result as a ll the
categories have at least a level 2 compliance score.
Iniave
Informaon Governance
Management
Confide nality and Da ta
Protecon Assurance
Informaon Security
Assurance
Clinical Informaon
Assurance
Secondary Use Assurance
Corporate Informaon
Assurance
Informaon Governance
Informaon Governance is the framework for handling
informaon in a confidenal a nd secure manner to the
appropriate ethical and qua lity standards in a mode rn health
service. It brings together inte rdependent re quirements and
standards of pracce in relaon to the IG iniaves
The IG Toolkit (IGT) is a self-assessment tool that sets the
requirements and standards that NHS organisaons need to
Level
achieved
2012
Grade
86%
Sasfactory
87%
Sasfactory
75%
Sasfactory
80%
Sasfactory
70%
Sasfactory
77%
Sasfactory
Informaon Governance Training and aware ness is
ulmately about changing the way pe ople behave: that is,
about changing the way people think and act. To achieve
that change in behaviour, all Trus t s taff are provided with
regular IG training.
Putting Patients First
30
2.6
Use of the Commissioning for Quality and Innovation (CQUIN) payment
framework
A proporon of Shrews bury and Telford Hos pital NHS Trust income in 2012/13 was condional on achieving
quality im provement and innovaon goals agreed be tween Shrewsbury and Telford Hospital NHS T rust and any pe rson or body
they entered into contract, agreement of a rrangement within England for the provision of NHS services, through the
Commissioning for Quality and Innovaon payment framework. Further details of the agreed goals for 2012/13 and for the
following 12 m onth period a re available ele ctronically at:
http://www.institute.nhs.uk/world_class_commissioning/pct_portal/cquin.html
No CQUIN Goal
1
VTE. Reduce avoidable death, disability and chronic ill health from Venous-thromboembolism (VTE). 90% of admitted Met
patients to have a VTE assessment every month.
2
Patient Experi ence. Improve responsiveness to personal needs of patients. Maintain or improve upon 2011/12 survey Not met
results (64.3).
3
NHS Safety Thermometer. Improv e collection of data in relation to pressure ulcers, falls, urinary tract infection in those Met
with a catheter, and VTE.
4
Improving Diagnosis of Dementia in Hospital. The use of a screening tool, a screening questionnaire and referrals to Partially
specialist dementia service.
met
5
Medicines Management. Drug regime changes y/n (and reasons why), renal function and allergy status recording.
6
Nutrition. Nutritional screening, assessment and delivery of an agreed individual action plan to maintain or improve an Met
'at risk' inpatients nutritional intake, protected mealtimes and red tray scheme.
7
Pressure Ulcers. 2hr assessments, care plans, 0 grade 3 and 4 ulcers and compliance to pressure sore handbook.
8
Net Promoter Question. Real time feedback to support the Patient Revolution work as embodied in the SHA Ambitions. Met
9
Maternity. To achiev e Baby Fri endly accreditation for SaTH Maternity Servic e at l evel 2 by April 2014
10
Making Every Contact Count. Development of MECC action plan with named impl ementation l ead, training and in- Met
creasing referrals to the ‘stop smoking’ service.
11
VTE Prophylaxis. Percentage of adult inpatients assessed to be at increased risk of VTE who receive appropriate Met
prophylaxis in line with the prescribed prophylaxis regime based on national guidance (NICE)
Partially
met
Partially
met
Met
There were goals relang to rena l dialysis, neonatal care and organ transplants for our contract with Specialise d Services,
summarised in table below:-
No CQUIN Goal
1
VTE. R educe avoidable death, disability and chronic ill health from Venous-thromboembolism (VTE). 90% of admitted
patients to have a VTE assessment every month.
Met
2
Patient Experience. Improve responsiveness to personal needs of patients. Maintain or improve upon 2011/12 survey
results (64.4).
Not met
3
NHS Safety Thermometer. Improve collection of data in rel ation to pressure ulcers, falls, urinary tract infection in those
with a catheter, and VTE.
Met
4
Improving Diagnosis of Dementia in Hospital. The use of a screening tool, a screening questionnaire and referrals to specialist dementia service.
Partially
met
5
Implementat ion of clinical dashboards for specialised services.
Ensuring that Providers implement and routinely use the required clinical dashboards for specialised services
Partially
met
6
Increasing use of home renal dialysis. To ensure patients are offered choice in their renal replacement therapy. Increase
number of patients receiving dialysis at home.
Partially
met
7
(Neonatal) Increase effectiv eness of hypothermia treatment
Met
8
(Neonatal) Discharge planning/family experi ence and confidence
Met
Putting Patients First
31
During 2012/13 2.5% of our contract values with PCTs in England will be based on achievement of 11 CQUIN goals. As in
2011/12, VTE and Improving Responsiveness to personal needs of patients remain national CQUIN goals and are joined by
national Safety Thermometer and Dementia goals. Local CQUIN goals are currently under discussion for inclusion in the
2013/14 contract. These are summarised in table below:
No
1
2
3
CQUIN Goal
Friends and Family. Phased expansion to include the Emergency Department and Maternity Services National requirement.
VTE screening performance target increased to 95%. National requirement.
NHS Safety Thermometer—using this prevalence audit to demonstrate a reducon in catheter associated urinary tract infecons.
4
Dementia. 90% of paents over 75 to be screened, risk assessed and referred on where appropriate, plus signposng to support
for carers of people with Demena. National requirement.
5
Medicines Management. Improved monitoring of anmicrobial use to contribute to C. Diff reducon and connuaon of an element from 2012/13 schedule relang to discharge communicaon with GP’s regarding the starng or stopping of medicaons.
6
Patient flow. To facilitat e safe discharge and early transfer.
7
Organisational culture. Values based recruitment across agreed staff groups
8
9
Falls reduction. Reduction in falls resulting in serious harm.
Maternity. Continuation of 12/13 Baby Friendly initiative.
There are goals relating to renal dialysis and for our contract with Specialised Services, summarised in the table below.
No
1
2
3
4
5
CQUIN Goal
Friends and Family. Phased expansion
VTE screening. Phased expansion. Target increased to 95%.
NHS Safety Thermometer. Moved from local to a national requirement.
Dementia. Phased expansion.
Clinical Quality Dashboards across specified clinical specialies
6
Neonatal retinopathy
7
Radiotherapy IGRT
8
Renal patient view & Acute Kidney Injury
Further details are available on http://www.institute.nhs.uk/world_class_commissioning/pct_portal/cquin.html.
Putting Patients First
32
2.7
Care Quality Commission (CQC)
registraon and compliance
The Shrewsbury and Telford Hos pital NHS
Trust is required to registe r with the Care Quality
Commission and its current registraon status is regis tered
without condions.
The Care Quality Comm ission has not taken any
enforcement acon against Shrewsbury and Telford
Hospital NHS Trust during 2012-2013 and the Trus t is not
subject to periodic review by the Care Quality Comm ission
The Shrewsbury and Telford Hospital NHS Trust has not
taken part in any special reviews or invesgaons by the
CQC under secon 48 of the Health and Social Care Act
2008 during 2012-13.
This secon of our Quality Account describes our
registraon with the Care Quality Commission (CQC), as
well as any reviews they have undertaken of our services
(either pe riodic reviews or special reviews). From 1 April
Outcome
2010 all provide rs of NHS services are re quired to register with the
Care Quality Commission. Registraon provides us with a “licence
to ope rate” to provide NHS services. To be registe red, NHS Trus ts
must show that they a re meeng essenal s tandards of quality and
safety. Compliance with these standa rds is m onitore d on a n
on-going basis by the Care Quality Comm ission.
Care Quality Commission Reviews
The Trust was reviewed by the CQC during unannounce d
inspecons in May 2012 (PRH) and August 2012 (RSH).
T he
reasons for the visits were; Princess Royal Hospital—part of the
CQC roune schedule of planne d reviews. Royal Shrewsbury
Hospital—part of a follow up s chedule of visits to the previous
Dignity and Nutrion scheme comm issione d by the Secretary of
State. Both visits conclude d that the re were no longer any
concerns regarding the ca re de livered against the assessed
standards and all previous concerns we re liSed. However, a furthe r
unannounced visit was carried out at the Princess Royal Hospital in
April 2013 and the Trust is awaing the formal report in relaon to
this.
.
CQC
Judgement
RSH
PRH
1: Respecng and involving people who use se rvices
Compliant
Compliant
4: Care and welfare of people who use services
Compliant
Compliant
5: Meeng nutrional needs
Compliant
Compliant
7: Safeguarding people who use services from abuse
Compliant
Compliant
13: Staffing
Compliant
Compliant
16: Assessing and monitoring the quality of se rvice provision
Compliant
Compliant
Putting Patients First
33
Annex 1
Statements from Local Involvement Networks, Health Overview and Scruny CommiIees and Primary
Care Trusts
Telford and Wrekin Loca l Involvement Network
During the past year much has improved in the quality and care of the paents, this has been achieved under difficult operang
circums tances.
We agree with the priories & objecves for the com ing year as outlined in the quality report. Working with all agencies within
the NHS will help with the flow of Paents within the T rust
It has bee n disappoinng that pressure s ores, falls, and mortality rates, whils t they have fallen slightly have not made s ignificant
improvements
We would like to see a greater improvement in outpaent waing mes as it is a cause of concern for many people. We would
like the Trust to implement mandatory tra ining for all Nursing Staff in the areas of Demena, Nutrion and the ca re of Paents
with Frail and com plex condions. We would also like to see a more robus t approach for dealing m ore swiSly with complaints.
We congratulate the Trust in making the quality accounts more use r friendly
Shropshire Council Hea lth Overview and Scruny CommiIee
The Commi6ee was sasfied with the content of the Quality Account document, and agreed with the priories set by the Trust,
which m irror naonal health priories in general. Members would like to commend the efforts taken by SaTH to engage with
Shropshire’s Healthy Comm unies Scruny Comm i6ee over the past 12 months, and were assured that this would connue to
develop in the future.
The development of pa rtne rship working and integrated thinking is seen as key to the success for not just the Trust, but the
whole hea lth e conomy. With sus tained high demand for unscheduled care, more and m ore pressures are being put on a cute
provide rs, but the developments being put in place by the Trust through its priories will go some way to improving pa ent
outcomes, developing servicing, and creang more efficient processes and protocols.
The Commi6ee was reassure d that the Trust was invesng in staff training and that the ‘Fundamentals of Care’ were addre ssed
for all wa rd s taff to ensure improvements in paent experie nce, but als o to enable s taff to understand how their role impacts on
paent outcomes. The Commi6ee was disappointed with the outcomes of the Staff Survey and would re quest that Trus t tak e on
board the conce rns raised through this document and work with s taff to improve.
Following the Francis Report, the Trust has undertaken to im prove its services and staffing to ensure paents are treate d with
dignity and care, and a re assured a safe clinical pathway throughout the ir journey.
The Commi6ee was sasfied with the content of the Quality Account, but stressed the nee d to provide an easy read version to
engage with the public and raise the profile of the document for the future.
The Commi6ee welcomed connued engagement with Healthy Comm unies Scruny Commi6ee in the coming year.
Telford & Wrekin Council Overview and Scruny CommiIee
Reconfiguraon
The Joint HOSC supported the Full Business Case for the reconfiguraon subje ct to furthe r approvals and assurances from the PCT
Cluste r and Strategic Health Authority.
The Joint HOSC focussed on the Travel and T ransport Plan. The Comm i6ee had inial conce rns but has been assured that the
local authority and othe r pa rtne rs are now fully involved.
Accident a nd Emergency Service a nd Ca pacity
The Commi6ee e xpressed concern about A&E services in August 2012 and there we re furthe r discussions with the Joint HOSC.
The Commi6ee remains e xtremely conce rned that the Trust is fa iling to meet naonal waing me targets and has decla red a
Level 4 on three occasions, and about the cancellaon of non-emergency operaons due to lack of A&E capacity. The Commi6ee
recognises tha t pressure on A&E is a naonal issue, but will connue to scrunise issues through the Joint HOSC to ensure
services are accessible, safe and sus tainable and awaits the outcome of the urgent care review.
The Joint HOSC considered the impact of delayed admission to A&E on ambulance availability for eme rgency calls. The
Commi6ee s uggests the quality account shows how the T rust is working with the ambulance se rvice to address this.
Reducon of Inpaent Falls
The Commi6ee s upports the connued focus on falls prevenon. The Joint HOSC heard that lessons would be lea rnt from the
coroner’s reports into the falls -related deaths.
Prevenng Avoida ble Pressure Ulcers
The Commi6ee is conce rned by the increase in reported Grade 3 and 4 pressure ulce rs despite prevenon being a priority.
Views of Paents and Staff
The Commi6ee is concerned about the results of the paent sasfacon survey and low s taff morale a nd will connue to
scrunise iss ues through the Joint HOSC.
Communicaon
The Commi6ee is pleased to see communicaon with family and carers as a priority. The Commi6ee’s review of Connuing
Healthcare (CHC) highlighted issues with this, although the Clinical Comm issioning Group is respons ible for CHC. The Commi6ee
also wants to ens ure that family and ca rers are provided with informaon about medicaon and follow-up procedures.
Putting Patients First
34
The Comm i6ee is conce rned the appointment system is not working effecvely. Members hea rd of paents receiving
confirmaon and reminde r le6ers a t the same me which is an unne cessary cost.
Commiss ioning for Quality a nd Innovaon (CQUIN)
The Comm i6ee recognises furthe r work is necessa ry to meet CQUIN targets and would like to see m ore informaon included,
parcularly on CQ UIN Goal 4 (demena ca re) to ensure all Trust front-line staff receive deme na training.
Blood Tes ts
The Commi6ee was concerne d about long waits for blood tests (without food) and would like to see how this will be improved
especially for diabec/frail paents.
Stroke Review
The Commi6ee will connue to monitor the outcome of the stroke services review through the Joint HOSC. The Comm i6ee wants
to ensure that acute and hyper-acute stroke services remain within the county and are sus tainable and accessible.
Shropshire Clinica l Commiss ioning Group & Telford and Wrekin Clinical Commissioning Group Joint S tatement
Shropshire Clinical Commissioning Group (SCCG) as the local Lead Comm issioning Organisaon m onitors the quality of the services
delivered by the Trust in conjuncon with Telford & Wrekin Clinical Comm issioning Group (TWCCG). This includes monthly re views
of performance and governance data, paent safety and expe rience metrics via Clinical Quality Review (CQR) meengs, announced
and unannounce d quality and safe ty review visits.
We believe that the Quality Account is reflecve of the Trusts a chievements and also outlines the challe nges it has faced in the
year in re laon to the s ustained delivery of both urgent and planned care; and a lack of achievement against both its own and
naonal priories for 2012-13 including the eliminaon of avoidable gra de 2, 3 a nd 4 press ure ulce rs and only paral achievement
of several Comm issioning for Quality and Innovaon (CQUIN) goals.
This Quality Account is the Trust’s annual report to the public about the quality of se rvices that a re de livered. While the document
provides lots of helpful informaon, it is generally presented from the points -of-view of the Trust’s internal processes (paent
safety, clinical effecveness, paent experience etc.). It is however worth note the Trust comm itment for 2013/14 to connue to
strive for best pracce in improving the paent journey and paent e xperience by connuing to streng then both paent and
public involvement.
“SCCG is fully supporve of the Trust’s quality priories for improvement that are idenfied for 2013/14 and comme nd its
commitment to focus on the culture of the organisaon “ To ensure that it is founded on the values of the Six C’s – Care,
Compass ion, Courage, Communicaon and Competence..” and to be “ A caring organisaon that always Puts Paents first.
Accuracy of Informaon
SCCG in line with its res ponsibilies has taken appropriate steps to assure the accuracy of data prese nted in the Trusts qua lity in
relaon to the locally commissioned se rvices and is sasfied that the SaTH NHS Trust DraS Quality Account 2012/13 provides a
level of assurance on a range of its se rvices.
Montgomeryshire Community Hea lth Council
Community Health Councils (CHCs) in Wales have a s tatutory respons ibility to represent the paents’ and general public’s
perspecve of health services, to keep under review the operaon of the health se rvice in its district and to make
recommendaons for the improvement of that se rvice. Hospita l monitoring and inspecon are two of the core funcons of the
CHC’s ‘quality monitoring’ programme of local health se rvices on behalf of paents and the public.
During 2011/12 Montgomeryshire Community Health Council has connue d to review the Trust’s health service provision to
Powys residents through CHC monitoring visits; inspecons; and feedback from paents. The Trust has connue d to send a s enior
representave to CHC Full Council meengs to respond to quesons raised by CHC membe rs and to e ngage with, consult and
advise CHC members of the Trust’s plans and proposals. The Trus t has responded to CHC concerns and re commendaons. These
have influenced its plans and priories for improvement, including the Quality Improvement Strategy; Quality monitoring and
improvement measures; and Quality Priories for 2012/13.
Montgomeryshire CHC has welcomed the opportunity to be part of the Trust’s Paent Experie nce Involvement Panel, and the
development of the work programme to support the review of paent ca re.
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35
We also welcome the approach taken by the T rust to act on both posive and negave feedback from our membe rs and from
Powys paents. T he CHC will connue to offer advice encouragement and support to the Trust whe re appropriate to e nable it to
achieve its aims on quality, safety, and paent experie nce.
Shropshire Hea lthwatch
Healthwatch Shropshire was es tablishe d on 1s t April 2013 to act as the independe nt consume r champion for health and social care
for the people of Shropshire. We are grateful for the opportunity to consider and comme nt on the Quality Account.
Healthwatch Shropshire has read the Quality Account carefully and can see the effort the T rust has put in to improving its
services. However, we would welcome more benchma rking of services against naonal data and also addional comme nts from
the Trus t to give more context to the data especia lly where objecves are only pa rally met.
Healthwatch Shropshire recognises that the Trust has a large volume of informaon which it is require d to include in the Q uality
Account but is conce rned that it is not easy to read and assimilate the informaon. We would like to see a “summa ry” document
highlighng the key issues for paents, service use rs and carers that is in a more accessible format.
Healthwatch Shropshire welcomes the propose d quality priories for 2013-14 and looks forwa rd to developing its relaonship
with the T rust during the year.
The feedback from our external stakeholde rs has been re plicated in its enrety without e dit.
Trusts response to feedback from stakeholders
In response to comments from external stakeholders, the Trust has made a small number of amendments to this
year’s Quality Account.
We have strived to make this year’s Quality Account more readable and clearer. We plan to distribute to a greater
number of public areas such as Leisure Centres, GP surgeries and civic buildings.
We have updated the glossary to reflect addional abbreviaons used within the Quality Account and removed
unnecessary ones.
We have produced a summary version of the Quality Account, which is available on request.
As in previous years, the Trust will endeavour to act upon all stakeholder feedback in order to a6ain year on year
improvements to the Quality Account.
Following interim feedback from stakeholder groups, we have made the following amendments to the Quality
Account.
•
We have expanded on the Workforce secon to include an update and response to our Staff Survey, and
included informaon on the role of our Educaon and Learning team, and their plans for 2013/14.
•
We have expanded the secon on Paent Services to highlight the development of the team, and also to
comment on the complaint response performance levels, and how these would be improved.
•
We have provided addional clarity on how we will deliver our quality performance priories for the coming
year and highlighted the key performance measures which will help us deliver them.
•
We have made a number of forma;ng amendments, based on advice from stakeholders, to improve the layout
and presentaon of the Quality Account.
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36
Annex 2.
Statement of directors’ responsibilies in respect of the Quality Account
The directors are required under the Health Act 2009 to prepa re a Quality Account for each financial year. The De partment of
Health has issue d guidance on the form and content of annua l Quality Accounts (which incorporates the legal requirements in
the Hea lth Act 2009 and the Naonal Health Service (Qua lity Accounts) Regulaons 2010 (as amended by the Naonal Health
Service (Quality Accounts) Amendment Regulaons 2011).
In preparing the Quality Account, dire ctors are required to take steps to sasfy themselves that:
•
The Quality Accounts presents a balance d picture of the trust’s performance over the pe riod covered;
•
The performance informaon re ported in the Quality Account is reliable and accurate;
•
There are proper inte rnal controls over the colle con and reporng of the measures of performance include d in the
Quality Account, and these controls a re subject to review to confirm that they are working effecvely in pracce;
•
The data underpinning the measures of performance reported in the Quality Account is robust and re liable, conforms to
specified data quality standa rds and pres cribed de finions, and is subject to a ppropriate scruny and review; and
•
The Quality Account has been prepa red in accordance with Depa rtment of Health guidance.
The directors confirm to the bes t of their knowledge and belief they have complied with the above requirements in preparing
the Quality Account.
By order of the Board:
Date:…………………………………………
Chair:………………………………………………………………………………….
Date: …………………………………………
Chief Execuve:………………………………………………………………...
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Annex 3.
KPMG Limited Assurance Audit report
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38
KPMG Limited Assurance Audit report (cont.)
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39
KPMG Limited Assurance Audit report (cont.)
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KPMG Limited Assurance Audit report (cont.)
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41
Glossary
CGE: Clinical Governance
Execuve
CHC: Community Health
Council
Clinica l Audit
Clinica l Governance
Clinica l Governance
Strategy
Clinica l Trials
Commiss ioners
Community Engagement
Forum
CPA: Clinical Pathology
Accreditaon
CQC: Care Quality Commission
CQUIN: Commissioning
for Quality and Innovaon
DATIX
EDD
HSMR: Hospital
Standardised Mortality
Rao
IS0 9000
Informaon Governance
Toolkit
KPI: Key Performance
Indicators
LINk: Local Involvement
Network
MDT
Community Health Councils in Wales have a statutory role to represent the interes ts of the
public in the health services in their district.
See www.wales.nhs.uk/chc
Informaon about clinical audit, including a definion, is available in Secon 2.2.2.
See www.hqip.org.uk
Clinical Governance is define d as: “A framework through which NHS organisaons a re
accountable for connually improving the quality of the ir services and safeguarding high
standards of care by creang an environment in which excelle nce in clinical care will flourish” (A
First Class Service: Quality in the New NHS, 1998).
This sets out our overall approach to clinical governance in the organisaon.
A clinical trial is a parcular type of research that tests one treatment against another. It may
involve either paents or people in good health, or both. Small studies produce less re liable
results so studies oSen have to be carried out on a la rge num ber of people before the results are
conside red reliable.
See www.nhs.uk/Condions/Clinical-trials and www.nihr.ac.uk
Commissioners are respons ible for ensuring adequate services are available for their local
populaon by assessing needs a nd purchasing services. Prima ry Care Trusts (PCTs) in England
and Local Health Boards (LHBs) in Wales are the key organisaons responsible for commissioning
healthcare se rvices for their area. Shropshire County Prima ry Care Trus t, Telford and W rekin
Primary Care Trus t and Powys Teaching Health Board purchase acute hos pital services from The
Shrewsbury and Telford Hospital NHS T rust for the populaon of Shropshire, Telford & W rekin
and mid Wales.
See www.shropshire.nhs.uk, www.telford.nhs.uk and www.powysthb.wales.nhs.uk
This is a regular meeng with paent and community representaves to help s hape T rust policy
and priories.
Clinical Pathology Accreditaon: An e xternal a udit and assessment process for pathology
services.
See www.cpa-uk.co.uk
The Care Quality Commiss ion is the inde pendent regulator of health and social care in England.
It regulates health and adult social care se rvices, whethe r provide d by the NHS, loca l authories,
private com panies or voluntary organisaons.
See www.cqc.org.uk
A new payment framework introduce d in the NHS in 2009/10 which means that a proporon of
the income of providers of NHS services is condional on meeng agreed targets for improving
quality and innovaon.
See www.instute.nhs.uk/cquin
The Shrewsbury and Telford Hospital NHS Trus t interna l incident re porng tool
An Expected Date of Discharge (EDD) is the date we think a paent will be able to safely leave
the hos pital. This da te is discussed and agreed by the team looking aSer the paent
The Hospital Standardised Mortality Rao (HSMR) is an indica tor of healthcare quality that
measures whether the death ra te at a hospital is higher or lowe r than you would expe ct
The ISO 9000 family of s tandards is related to quality management systems and designe d to help
organizaons ens ure that they meet the nee ds of custome rs and other stakeholders while
meeng statutory and regulatory requirements
This is an tool to support NHS organisaons to assess and improve the way they manage
informaon, including paent informaon
See www.igt.connecngforhea lth.nhs.uk
A set of de fined measures which s how progress against the target
Local Involvement Ne tworks in England are made up of individuals and community groups
working togethe r to im prove local services. The ir job is to find out what the public like and dislike
about local health and social care. They will then work with the people who plan and run these
services to improve them. T his may involve talking directly to healthcare professionals about a
service tha t is not being offered or suggesng ways in which an exisng se rvice could be made
be6er.
Mul Disciplinary Team—A group of health care professionals who provide differe nt services for
paents in a co-ordinate d way
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MHRA
MRSA
NHSLA
NPSA
Overview and Scruny
CommiIees
Paent Experience
Reporng
PEAT
PEIP
Periodic Reviews
Pressure Ulcers
PROMs
PSAG
Quality and Safety
Assurance Framework
RCA
Risk Management
systems
SaTH: The Shrewsbury
and Telford Hospital NHS
Trust
Safety Thermometer
SHMI
Special Review
Trust Board
VTE:
Venous
Thromboembolism
The Medicines and Healthcare Products Regulatory Agency (MHRA) is a UK government agency
which is responsible for ensuring that medicines and medical devices work and are acceptably
safe.
Methicillin-resistant Staphylococcus aure us (MRSA) is a bacterium responsible for several difficultto-treat infecons.
The NHS Ligaon Authority is a not-for-profit part of the NHS. It manages negligence and other
claims against the NHS in England on behalf of membe r organisaons.
The NPSA is an arm's length body of the Depa rtment of Health. It was established in 2001 with a
mandate to idenfy paent safety issues and find appropriate soluons
Overview and Scruny Commi6ees in local authories have statutory roles and powers to review
local health se rvices.
See www.shropshire.gov.uk and www.telford.gov.uk
We ask our paents to tell us about their expe rience of our services in a variety of ways. These
include the CQC Annual Inpaent Survey our own inte rnal surveys and the com plaints and compliments we re ceive from paents and care rs.
Paent Environme nt Acon Team
This stands for Paent Expe rience and Involvement Panel. This group brings together paents,
carers, paent representaves and se nior staff to make on-going improvements to paent care and
experie nce.
Periodic Reviews are reviews of health services carried out by the Care Quality Commission. The
term “review” refe rs to an assessment of the quality of a se rvice of the impact of a range of
commissione d services, using the informaon that the CQC holds about them, including the views
of people who use those se rvices.
Pressure ulce rs are also known as pressure sores, or bed sores. They occur when the skin and
underlying ssue becomes damaged. In very serious cases, the underlying mus cle and bone can
also be damaged.
See www.nhs.uk/condions/pressure -ulcers
Paent Reporte d Outcome Measures - PROMs measure a paent's health status or hea lth-related
quality of life at a single point in me, and are collected through short, self-completed
quesonnaires.
Paent Status at a Glance. An SaTH developed electronic paent board which shows clinical
teams what intervenons the paent requires. Provides basis to manage demand and capacity.
This framework sets out how aspects of governance and safety are to be integrated into the
Trust’s arrangements and how quality will be connually im proved and monitored.
Root Cause Analysis.
An invesgaon which takes place to find out the cause of a problem which has occurred
These enable staff across the organisaon to ide nfy and report risks to the quality of care. The
organisaon is then be6e r able to manage these risks, focusing on addressing those issues that
are more likely to have a greater adverse impact on paent experie nce, safety and effecveness.
The Shrewsbury and Telford Hos pital NHS Trust, the NHS organisaon responsible for hos pital
services at the Princess Royal Hospital in Telford and the Royal Shre wsbury Hospita l in
Shrewsbury. We are the main provide r of acute hospital se rvices for around half a million people
in Shropshire, Telford & Wrekin and mid Wales.
See www.sath.nhs.uk
The NHS Safety The rmomete r is a local improvement tool for measuring, monitoring and analysing
paent harms and 'harm free' care
Summary Hospital-Level Mortality Indicator.
A special review is carried out by the Ca re Quality Commission. Each special review looks at
themes in health and social care. They focus on services, pathways or care groups of people. A
review will usua lly result in assessments by the CQC of local health and social care organisaons, as
well as supporng the idenficaon of naonal findings.
The Trust Board takes corporate respons ibility for the organisaon’s strategies and a cons. The
chair and non-execuve directors a re lay people drawn from the local community and a re
accountable to the Secretary of State. The chief execuve is responsible for ensuring that the
board is empowe red to govern the organisaon and to deliver its objecves.
Venous thromboem bolism (VTE) is a term that covers both Dee p Vein Thrombosis (DVT, a blood
clot in one of the deep veins in the body) and pulm onary embolism (whe re a piece of blood clot
breaks off into the bloodstream and blocks one of the blood vessels in the lungs).
See www.nhs.uk/condions/deep-vein-thrombosis
Putting Patients First
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Acknowledgements
We would like to thank the following people for the ir contribuon and
generous feedback which has shape d this year’s Quality Account.
•
•
•
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•
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•
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•
•
•
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Health and Safety Manager
Specialist Praconer in Blood Transfusion
Associate Director of Quality and Paent E xperience
Centre Manager—Therapies
Diabec Clinical Nurse Specialist
Deputy Chief Nurse
Medical Performance Manager
Business Manager—Estates and Facilies
Paent Safety Team Manager
Paent Services Manager
Programme Manager - Future Configuraon of Hospital Services
Chief Informaon Officer
Clinical Governance Manager
R&D/Clinical T rials Manager
Data Quality Manager
Informaon Governance Manager
Contracts and Performance Manager
Hygiene and Com pliance Officer
Head of Business Informaon
Contracts & Pe rformance Manager
Senior Human Res ources Manager
Improvement Manager—Corporate Nursing
Members and contributors from the following g roups
•
Shropshire Clinical Commissioning Group
•
Telford a nd Wrekin Clinica l Comm issioning Group
•
Telford & Wrekin Local Involvement Networks (LINKs)
•
Shropshire Healthwatch
•
Shropshire and Telford & W rekin Health Overview and Scruny
Commi6ees (HOSC)
•
Montgomery Community Health Council (CHC)
Putting Patients First
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Putting Patients First
45
Informaon about this Quality Account
Copies a re available from www.sath.nhs.uk, by email (consultaon@sath.nhs.uk) or in wring from:
Chief Execuve’s Office, The Shrewsbury and Telford Hospital NHS Trust, Princess Royal Hos pital, Grainger Drive, Apley Castle,
Telford TF1 6TF
Chief E xecuve’s Office, The Shrewsbury and Telford Hospital NHS T rust, Royal Shrews bury Hospital, My6on Oak Road, Shre wsbury, Shropshire SY3 8XQ
Our Quality Account is also available on request in large print.
Please contact us at the address above or by email at
consultaon@sath.nhs.uk to request a large print version of the
Quality Account.
Please also contact us if you would like to request a copy of our Quality Account in anothe r community
language for people
in Shropshire, Telford & Wrekin and mid Wales.
A glossary is provided at the e nd of this document to expla in the main terms a nd abbreviaons used in our Quality Account.
www.sath.nhs.uk
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