United Lincolnshire Hospitals Trust
Quality Account 2012/13
United Lincolnshire Hospitals Trust – Quality Account 2012/13
1
Contents
Part 1
Contents
Statement on Quality from the Chief Executive ........................................................................ 6
Statement of directors' responsibilities in respect of the quality account ............................... 7
Introduction ............................................................................................................................... 8
Areas for improvement in 2013/14 ........................................................................................... 9
Priority 1 - Reducing Hospital Mortality .............................................................................. 10
The issue explained .......................................................................................................... 10
Current status .................................................................................................................. 10
Aims and goals for 2013/14 ............................................................................................. 11
How we will assess our progress ..................................................................................... 11
Priority 2 - Reducing healthcare associated infections........................................................ 13
The issue explained .......................................................................................................... 13
Current status .................................................................................................................. 13
Aims and goals for 2013/14 ............................................................................................. 13
How we will assess our progress ..................................................................................... 13
Priority 3 – Eliminating avoidable pressure ulcers .............................................................. 15
The issue explained .......................................................................................................... 15
Current status .................................................................................................................. 15
Aims and goals for 2012/13 ............................................................................................. 15
How we will assess our progress ..................................................................................... 15
Priority 4 – Safe discharge of patients ................................................................................. 16
The issue explained .......................................................................................................... 16
Current status .................................................................................................................. 16
Aims and goals for 2013/14 ............................................................................................. 16
How we will assess our progress ..................................................................................... 17
Priority 5 – Senior Daily Review ........................................................................................... 18
The issue explained .......................................................................................................... 18
Current status .................................................................................................................. 18
United Lincolnshire Hospitals Trust – Quality Account 2012/13
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Aims and goals for 2013/14 ............................................................................................. 18
How we will assess our progress ..................................................................................... 18
Statements of assurance.......................................................................................................... 19
Review of services ............................................................................................................ 19
Participation in Clinical Audits ......................................................................................... 19
Participation in Clinical Research ......................................................................................... 29
Commissioning for Quality and Innovation (CQUIN) ........................................................... 31
Care Quality Commission (CQC) Statements ....................................................................... 32
Data quality .......................................................................................................................... 35
NHS Number and General Medical Practice Code validity .................................................. 35
Clinical coding error rate...................................................................................................... 35
Information Governance Toolkit attainment levels ............................................................ 36
Reporting of harm to patients ............................................................................................. 36
Data provided by the Health and Social Care Information Centre ...................................... 37
Review of quality performance................................................................................................ 42
Organisational arrangements and initiatives to embed quality .......................................... 42
Patient Safety ................................................................................................................... 42
Effectiveness of Care........................................................................................................ 45
Monitoring and learning from clinical experience .......................................................... 45
Innovation and improvement – Transforming Our Services ........................................... 46
Supporting our workforce to deliver high quality care ................................................... 53
Review of 2012/13 improvement priorities ............................................................................ 56
Priority 1 – reducing our Hospital Standardised Mortality Rate (HSMR) ............................ 57
What are mortality indicators? ........................................................................................ 57
How should mortality indicators be used? ...................................................................... 57
What have we achieved? ................................................................................................. 58
Current status .................................................................................................................. 59
Key improvement initiatives ............................................................................................ 59
What this means for patients .......................................................................................... 59
Priority 2 – Continuing to meet the nutritional needs of our patients ............................... 60
What have we achieved? ................................................................................................. 60
Current status .................................................................................................................. 60
United Lincolnshire Hospitals Trust – Quality Account 2012/13
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Key improvement initiatives ............................................................................................ 61
What does this mean for patients? ................................................................................. 61
Priority 3 – reducing healthcare associated infections........................................................ 62
What have we achieved? ................................................................................................. 62
Current status .................................................................................................................. 62
Key improvement initiatives ............................................................................................ 62
What this means for patients .......................................................................................... 63
Priority 4 – continuing to develop reliability in risk assessment and prophylaxis for venous
thromboembolism (VTE)...................................................................................................... 64
What have we achieved? ................................................................................................. 64
Current status .................................................................................................................. 64
Key improvement initiatives ............................................................................................ 65
What this means for patients .......................................................................................... 65
Priority 5 – improved handling of complaints ..................................................................... 66
What have we achieved? ................................................................................................. 66
Current status .................................................................................................................. 66
Key improvement initiatives ............................................................................................ 66
What this means for patients .......................................................................................... 67
Priority 6 – improving the safe discharge of our patients ................................................... 68
What have we achieved? ................................................................................................. 68
Current status .................................................................................................................. 68
Key improvement initiatives ............................................................................................ 68
What this means for patients .......................................................................................... 69
External regulation and assurance .......................................................................................... 70
Care Quality Commission (CQC) .......................................................................................... 70
NHS Litigation Risk Management Standards (Acute)........................................................... 70
Clinical Negligence Scheme for Trusts ULHT Maternity Services ........................................ 70
Quality Overview...................................................................................................................... 71
ULHT Performance at a Glance - March 2013 ......................................................................... 72
Stakeholder comments ............................................................................................................ 74
NHS Lincolnshire West Clinical Commissioning Group (Lead Commissioner)..................... 74
Health Scrutiny Committee for Lincolnshire and Healthwatch Lincolnshire. ..................... 76
United Lincolnshire Hospitals Trust – Quality Account 2012/13
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Patient Council ..................................................................................................................... 78
Appendix: Governance Statement 2012/13 ............................................................................ 79
Scope of responsibility ......................................................................................................... 79
The governance framework of the organisation ................................................................. 79
Trust Board and Committee Structure ................................................................................ 80
Supporting Committee Structures ....................................................................................... 80
Risk assessment ................................................................................................................... 81
Trust Major Risks during 2012/13 ....................................................................................... 81
The risk and control framework .......................................................................................... 82
Review of the effectiveness of risk management and internal control .............................. 83
Significant Issues .................................................................................................................. 84
Appendix 2: Independent Auditor’s Limited Assurance Report To The Directors Of United
Lincolnshire Hospitals Nhs Trust On The Annual Quality Account .......................................... 86
United Lincolnshire Hospitals Trust – Quality Account 2012/13
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Statement on Quality from the Chief Executive
Nothing is more important at United Lincolnshire Hospitals than the safety and quality of
the care we provide. It is our number one priority and we focus on it every day.
This is why the Quality Account is so important. It is an opportunity for us to present
evidence of how we are doing across a wide range of measures and in considerable detail. It
shows where the Trust is performing well and where we have identified we need to do
better.
Our approach to quality is based on four key principles:
1.
2.
3.
4.
Patient safety (for example, by minimising the risk of infection)
Clinical effectiveness (delivering good outcomes for patients)
A good patient experience (ensuring dignity and the right levels of care)
Continuous improvement (constantly questioning ourselves in order to do things
better)
We know we are on a journey of improvement. Our progress has been highlighted by the
Care Quality Commission, which has reported dramatic advances at both Lincoln and Pilgrim
Hospitals during 2012/13. This has been achieved through a relentless pursuit of clinical
excellence - promoting and encouraging best practice, whilst eradicating that which does
not meet the high standards we have set ourselves. We now have visual displays of our care
performance on every ward, carry out regular inspections and review every death.
Despite the financial pressures we face, the Trust has recruited additional doctors and is
investing in more nurses. The progress of the past year is the result of the hard work,
dedication and skill of all our staff. We ask them to be accountable for their actions and
encourage them to raise any concerns.
Our philosophy of excellence is shaped by the knowledge that we and the people of
Lincolnshire want nothing but the best. That is as it should be. We will continue to do
everything in our power to meet that expectation.
Jane Lewington
Chief Executive
United Lincolnshire Hospitals Trust – Quality Account 2012/13
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Statement of directors' responsibilities in respect of the quality account
The directors are required under the Health Act 2009, National Health Service (Quality
Accounts) Regulations 2010 and National Health Service (Quality Account) Amendment
Regulation 2011 to prepare Quality Accounts for each financial year. The Department of
Health has issued guidance on the form and content of annual Quality Accounts (which
incorporate the above legal requirements).
In preparing the Quality Account, directors are required to take steps to satisfy themselves
that:
• the Quality Accounts presents a balanced picture of the Trust’s performance over
the period covered;
• the performance information reported in the Quality Account is reliable and
accurate;
• there are proper internal controls over the collection and reporting of the measures
of performance included in the Quality Account, and these controls are subject to
review to confirm that they are working effectively in practice;
• the data underpinning the measures of performance reported in the Quality Account
is robust and reliable, conforms to specified data quality standards and prescribed
definitions, is subject to appropriate scrutiny and review; and the Quality Account
has been prepared in accordance with Department of Health guidance.
The directors confirm to the best of their knowledge and belief they have complied with the
above requirements in preparing the Quality Account.
By order of the Board
Jane Lewington
Chief Executive
United Lincolnshire Hospitals Trust – Quality Account 2012/13
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Introduction
This quality account describes our priorities and focused actions for future (Part 2) and also
our progress over the past year (Part 3). Our achievements over the past year, described in
Part 3, include:
•
•
•
•
•
•
Significant improvements in response to and learning from patients’ and relatives’
concerns.
A sustained achievement in VTE prevention
Continuing improvement in the reliability of key ward care processes.
Continuing progress in our reliability in meeting the nutritional needs of our patients
through assessing individual vulnerabilities and rapidly responding to dietary needs
Some reduction in mortality as measured by Hospital Standardised Mortality Rates,
though further work is needed to meet our ambitions to reduce these levels
Improved performance in assuring continuity of care through sustained improvemen
in electronic discharge documents.
Other central initiatives in patient safety, organisational learning systems and in managing
patient flow through our systems are also described in Part 3 of this report.
Part 2 describes priority areas for the coming year. Many of these are carried over from
2011/12; this does not reflect any lack of progress in our priority areas, but rather their
continuing importance to our patients the consistent, focused approach of the Trust.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
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Part 2
Areas for improvement in 2013/14
In 2013/14, we will continue to maintain our focus on priority areas, of which there are five
for 2013/14. These areas each relate to the accepted quality domains of patient safety,
clinical effectiveness and patient experience and are for the most part a continuation of our
previous initiatives. Though significant initiatives in many other areas are taking place
across the Trust and are also described in this document, our chief focus in the coming year
will be upon:
•
•
•
•
•
Reducing our Hospital Standardised Mortality Rate (HSMR)
Reducing healthcare associated infections
Eliminating avoidable pressure ulcers
Improving the safe discharge of our patients
Daily senior review of all patients
A description of our aims and monitoring arrangements for each of these six areas is
provided in the following sections.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
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Priority 1 - Reducing Hospital Mortality
The issue explained
Hospital Standardised Mortality Ratio (HSMR) compares a Trust’s actual number of deaths
with a national average number of deaths, adjusted for the mix of cases treated by each
hospital. This assessment takes into account many factors such as age, sex, diagnosis, the
nature of the admission (planned or unplanned) and other key factors. An HSMR of 100
would indicate that the expected number of deaths was exactly as expected given the casemix at the Trust; above or below this figure reflects either the “random” variation (which
would be expected in all such data), or genuine (that is, statistically significant) deviations.
Where it is the latter, and Trust performance is either better or worse than the average, this
is indicated clearly in the data so that it can be reviewed by the Trust.
A further measure of mortality is the Standardised Hospital Mortality Indicator, or SHMI.
Unlike HSMR, this indicator includes all diagnoses and also deaths which occur up to 30 days
after discharge.
Current status
HSMR and SHMI are monitored based on data provided by Dr Foster Intelligence, an
independent company widely employed to analyse data from NHS Trusts. As a Trust, ULHT
continues to experience a mortality rate higher than average. Although the most recent
data show Trust performance at within the limits expected by random variation, changes in
national means (which will be made in September 2013) are expected to increase our
mortality levels to “outlier” status.
There is considerable variation across Trust sites. Pilgrim Hospital Boston and Grantham
District Hospital are expected to be within acceptable limits, but Lincoln County Hospital has
shown an increasing trend in recent months and will be a key target for improvement.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
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Figure 1: Trust HSMR Apr 2012 – Mar 2013
Aims and goals for 2013/14
We wish to reduce mortality levels and become a Trust with lower than expected mortality.
Many of our quality improvement programmes will contribute to achieving a lower HSMR.
In particular, we will focus our efforts on:
•
•
•
•
•
•
•
Ensuring that all patient deaths are independently reviewed in order to establish
a coherent evidence base for change
Introduction of evidence-based care bundles for conditions leading to high
volumes of patient deaths, including septicaemia and pneumonia
Monitoring and improving care process reliability in the areas of ward processes,
medication safety and medical processes
Monitoring the appropriateness of admissions for end-of-life care
Ensuring that clinical records accurately reflect our provision of palliative care
and the comorbidities of our patients
Ensuring that critical care outreach provision supports patients who may
deteriorate in our care
Ensuring that key safety behaviours such as hand hygiene, the use of safe surgery
systems, and other key actions become “Always Events”
How we will assess our progress
Data are analysed in detail every month and assessed by the Trust Mortality Reduction
Boards, chaired by the Trust Medical Director at pan-Trust level and by deputy medical
United Lincolnshire Hospitals Trust – Quality Account 2012/13
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directors at site level. These multidisciplinary bodies examine data by hospital site,
diagnosis and speciality and identifies any deviations from expectation.
We will continue our programme of mortality reviews to develop understanding and action
as to when and where untoward deaths take place with a view to changing practices and
thereby reducing deaths which would be unexpected when compared to national statistics
for similar Trusts.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
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Priority 2 - Reducing healthcare associated infections
The issue explained
Healthcare associated infections in hospitals are caused by a wide variety of organisms and
bring about a range of symptoms from minor discomfort to serious disability or sometimes
death. Nationally, many thousands of people are affected by, for example, meticillin
resistant Staphylococcus aureus (MRSA), bloodstream infections or Clostridium difficile (C.
difficile).
Current status
The Trust has performed well in managing and preventing healthcare associated infections,
but exceeded its trajectory for C. difficile. There is a continuing focus on emerging risks
relating to sensitive strains of Staphylococcus aureus and other organisms which will require
continuing focus and vigilance.
Aims and goals for 2013/14
During 2013/14, we will maintain the substantial focus already in place to reduce the
infections against which the Trust has Department of Health (DH) targets, namely Meticillin
Resistant Staphylococcus aureus bacteraemia (target for 2013/2014 = 0) and Clostridium
difficile (target for 2013/2014 = ≤ 52).
Additionally, there is continued national focus on other organisms, including strains of
Staphylococcus aureus and also E.coli bacteraemias. The Trust will continue to contribute to
national reporting of these whilst at the same time working with staff across the
organisation to reduce risk factors which might result in patients acquiring these infections.
Some of these risk factors include insertion and aftercare of intravenous cannulae and
urinary catheters, as well as antibiotic management and environmental cleanliness. We will
adopt a rigorous approach to accountability where we identify staff behviours which
increase the risk of infections, including hand hygiene and “bare below the elbow”
behaviour on wards.
Where infections have occurred, we will conduct in-depth analyses of events and ensure
that learning from incidents is effectively shared.
How we will assess our progress
The Trust will continue to report cases of MRSA bacteraemia, MSSA bacteraemia, E. coli
and C. difficile via the national mandatory reporting system and will comply with any
additional in-year reporting requirements. Monthly data for infections will to be monitored
and reported to the Trust Board. We will continue to display our infection rates publicly to
ensure that our patients and staff are aware of the progress that we are making.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
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Levels of, and reliability in the management of, catheterisation will be monitored monthly
through the Safety and Quality Dashboard. Targeted audits will be conducted as
appropriate by the infection control team.
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Priority 3 – Eliminating avoidable pressure ulcers
The issue explained
Pressure ulcers are a significant risk to patients’ health and comfort and represent a
frequently avoidable harm. The management of pressure ulcers in a hospital setting
requires a close examination of patients – especially those who are frail and elderly – to
identify those at risk or those who already have deterioration in skin tissue, followed by
reliable management of key factors. These include mobility, continence and the provision of
appropriate equipment such as suitable mattresses.
Current status
During 2012/13 our overall performance both in terms of the reliability of key care
processes and the incidence of avoidable pressure ulcers improved. However, there was
some apparent increase during the last month of the year, indicating that a renewed and
intensive focus on this area is required.
Aims and goals for 2012/13
During 2013/14, we will aim to eliminate hospital-acquired pressure ulcers/ This will be
achieved though:
•
•
•
•
Ensuring that risk assessments and reassessment are accurate
Ensuring that care plans are produced, enacted and evaluated individually for
each patient at risk
Ensuring that the right equipment is provided for patients at risk
Ensuring that management of existing pressure ulcers conforms to best
practice and is reliably applied to all.
How we will assess our progress
Pressure ulcer prevalence will be assessed through the monthly point prevalence audit, the
Safety Thermometer. Care process reliability will be assessed through our Safety and
Quality Dashboard.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
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Priority 4 – Safe discharge of patients
The issue explained
Safe discharge of patients, with appropriate communication to patients and partners in
healthcare affect patient quality and safety through readmission rates, length of stay, health
outcomes and cost to patients and healthcare providers. It is especially important to ensure
that timely and accurate information accompanies the patient and is available to the
patient, carers and partners.
Current status
The Trust has made significant improvements in the reliability of electronic discharge
documentation, though more work needs to be done to ensure that all discharges are
managed correctly.
We recognise through audit that staff are committed to delivering an excellent service to
patients, there are examples of good practice on all sites and in allorganisations/agencies,
and that staff work hard to discharge patients despite the constraints of the wider system.
There is, however, a need to simplify the system, re-emphasise the role of early planning
and address the cross-boundary transfer of patients through, for example, a “Trusted
Assessor” model.
Our key measure for the reliability is the “Electronic Discharge Document” or eDD. During
2013/14, approximately 70% our patients received an eDD within 24 hours of discharge.
Aims and goals for 2013/14
Reliable and safe discharge of patients requires a co-ordinated approach involving both
United Lincolnshire Hospitals and a wide range of other agencies. Following our work in
2012/13, recommendations include:
• Development of a multi-disciplinary discharge plan for use by all staff supporting
patient discharge in ULHT and ensure that it commences within 24 hours of
admission
• Clear accountability and performance feedback to responsible clinicians and clinical
groups
• Use of a lead professional, depending on the patient’s need, to be responsible for
setting and reviewing discharge plans
• Implementation of the ULHT Discharge Policy
• Implement Multi-disciplinary Team Board rounds to focus on discharge planning
• Review the need for a dedicated discharge planning team at ward level linked to
complex elderly patients
United Lincolnshire Hospitals Trust – Quality Account 2012/13
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How we will assess our progress
During the coming year, we will continue to focus on the timely completion of eDD at Trust,
site, business unit, ward and consultant level. Data are reported monthly for review by the
Directorate Performance Clinics and Trust Board.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
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Priority 5 – Senior Daily Review
The issue explained
The Academy of Royal Colleges agree that patients outcomes improve, mortality decreases
and patients have a better experience if their care is managed on a daily basis by a senior
clinical decision maker.
Current status
The Trust has made significant investment in consultant grade doctors in order to achieve
reliability in daily review, principally at Pilgrim Hospital Boston. The attainment here was
also a CQUIN for the previous financial year and we were able to build reliability as
measured by single-point audit to over 90%.
Aims and goals for 2013/14
Our key goals for 2013/14 are to continue to build reliability of senior daily review and to
extend this to seven-day working across all sites.
How we will assess our progress
We will measure our progress though audit of reviews and qualitiative assessment of
completeness, using tools standardised in the previous year. We expect the effects of this
initiative to be visible in the areas of reduced mortality, reduced length of stay, reduced
occupancy, improved patient outcomes, reduction in complaints.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
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Statements of assurance
Review of services
During 2012/13, United Lincolnshire Hospitals NHS Trust (ULHT) provided and/or subcontracted 48
NHS services. We have reviewed all the data available to us on the quality of care in all of these 48
NHS services.
The income generated by the NHS services reviewed in 2012/13 represents 90.7% of the total
income generated from the provision of NHS services by the Trust for 2012/13.
Participation in Clinical Audits
Between 1st April 2012 and 31st March 2013, ULHT took part in 33 national clinical audits. In
addition, we participated in three national confidential enquiries covering NHS services that
United Lincolnshire NHS Trust provides. This means that United Lincolnshire Hospitals Trust
participated in 86.8% of possible national clinical audits and 100% of the national
confidential enquiries in which it was eligible to participate.
Details of these audits and enquiries are provided below, together with the number of cases
submitted to each audit or enquiry as a % of the number of registered cases required by the terms of
that audit or enquiry.
ULHT
Participation
Reporting Period
Number and %
required
Perinatal Mortality (MBRRACE-UK)
N/A new system
not in place yet
HQIP appoint
contract July
2012
New national data
collection system to
commence Late March
early April 2013
N/A
Neonatal Intensive and Special care
(NNAP)
Yes
1 January – 31
December 2011 (report
published July 2012)
732 (100%)
National Audits
ULHT
Participation
Reporting Period
Number and %
required
Yes
1 November 2012 – 31
January 2013
National Audits
Peri- and Neonatal
st
st
Children
Paediatric Pneumonia (British Thoracic
Society)
st
United Lincolnshire Hospitals Trust – Quality Account 2012/13
st
8 eligible children
19
st
th
Paediatric Asthma (British Thoracic
Society)
Yes
1 November 2012 -30
November 2012
34 eligible children
Fever in Children (College Emergency
Medicine)
Yes
August 2012- November
2012
90/150 (60%)
Childhood Epilepsy (RCPH National
Childhood Epilepsy Audit)
Yes
1st May 2011 (children
who presented in the
previous twelve months to
st
the census day of 1 May
2011
12 (100%) eligible
children
Paediatric Intensive Care (PICANet)
N/A
This audit is only
applicable to specialist
centres
N/A
Paediatric Cardiac Surgery (NICOR
Congenital Heart Disease Audit)
N/A
This audit is only
applicable to specialist
centres
N/A
Diabetes (RCPH National Paediatric
Diabetes Audit)
Yes
1 April 2010 – 31 March
2011
National report
confirms participation
only not number of
submissions
Emergency Laparotomy
N/A (awaiting
tendering
process)
HQIP appointed contract
to Royal College Surgeons
audit to commence with
organisational audit late
2013.
N/A data not collected
during this period
Cardiac Arrest (National Cardiac Arrest
Audit) ICNARC
Yes
1 April 2012- 31
December 2012
National Audits
ULHT
Participation
Reporting Period
Renal Colic (College of Emergency
Medicine)
Yes
1 August 2012- 30
November 2012
Adult Community Acquired Pneumonia
(British Thoracic Society
Yes
1 December 2011 - 31
January 2012
Bronchiectasis (British Thoracic Society)
No
Emergency use of Oxygen (British
Thoracic Society)
Partial
st
st
Acute Care
st
st
st
214 (no case
ascertainment noted in
the report)
Number and %
required
th
st
127/150 (84.6%)
st
th
15 August 2012 – 1
November 2012
United Lincolnshire Hospitals Trust – Quality Account 2012/13
135
N/A
st
16
20
Adult Critical Care (Case Mix
Programme) ICNARC
Yes
2012
1797 (100%)
Long Term Conditions
Diabetes (National Adult Diabetes Audit)
No
-
N/A
Heavy Menstrual Bleeding (RCOG
National Audit of HMB)
Yes
1 February 2011 – 31
January 2012 baseline
questionnaires completed
by consenting women
190/432 (44%)
Chronic Pain (National Pain Audit)
Yes
March 2010- June 2012
Phase 2 159
Phase 1 registration and
service provision
Phase 3 86
st
st
Awaiting 2013 report
on follow up
questionnaires
Phase 2 case mix
information
Phase 3 patient reported
Dementia
Yes
April 2012- October 2012
Ulcerative Colitis & Chron’s Disease
(National IBD Audit)
Yes
1 September 2010 – 31
August 2011
71 (89%)
Parkinson’s Disease (National
Parkinson’s Audit)
No
N/A
N/A
National Audits
ULHT
Participation
Reporting Period
Number and %
required
COPD
N/A
N/A national tendering in
process to commence
during 2013/14
N/A
Adult Asthma (British Thoracic Society)
Yes
1 December 2011 - 31
January 2012
Hip, Knee and Ankle Replacements
(National Joint Registry)
Yes
1 January 2012-31
December 2012
National Elective Surgery Patient
Reported Outcome Measures ( National
PROMs Programme) (4 operations)
Yes
PROMs April 2012 –
September 2012
(published February 2013)
st
st
st
st
116/120 (96.6%)
21 (check Grantham)
Elective Procedures
st
1.Varicose Veins
United Lincolnshire Hospitals Trust – Quality Account 2012/13
st
1176 submitted
records (NJR do not
provide % case
ascertainment)
Patient participation
rate (patients who
completed a preoperative
questionnaire
21
2.Groin Hernia
1. 38.0%
3.Hip Replacement
2. 53.2%
4.Knee Replacement
3. 80.2%
4. 82.1%
Cardiothoracic Transplantation (NHSBT
UK Transplant Registry)
N/A
This audit is only
applicable to specialist
centres
N/A
Liver Transplantation (NHSBT UK
Transplant Registry)
N/A
This audit is only
applicable to specialist
centres
N/A
Coronary Angioplasty (NICOR Adult
Cardiac Interventions Audit)
Yes
2012-2013
Not available data
taken from BCIS data
Vascular Surgery (VSGBI Vascular
Surgery Database)
Yes
1 October 2008 – 30
September 2010
Carotid Interventions (Carotid
Interventions Audit)
Yes
1 October 2010- 30
September 2011 (patients
operated on during this
period)
28/45 (62%)
National Audits
ULHT
Participation
Reporting Period
Number and %
required
Coronary Artery Bypass Graft (CABG)
and Valvular Surgery (Adult Cardiac
Surgery Audit)
N/A
This audit is only
applicable to specialist
centres
N/A
Stroke Care (National Sentinel Audit of
Stroke) SSNAP
Yes
April 2012
Organisation of
services audit
completed.
Acute Myocardial Infarction & Other
Acute Coronary Syndrome (MINAP)
Yes
2011-2012
1311 (100%)
Heart Failure
Yes
2011-2012
253 (104%)(240
expected)
Pulmonary Hypertension
N/A
This audit is only
applicable to specialist
centres
N/A
st
st
th
th
39 (75.4%) of the
expected
Cardiovascular Disease
Renal Disease
United Lincolnshire Hospitals Trust – Quality Account 2012/13
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Renal Registry)
Yes
2012-2013
Not available satellite
centre for Leicester
General
Renal Transplantation (NHSBT UK
Transplant Registry)
Yes
2012-2013
Not available satellite
centre for Leicester
General
Lung Cancer (LUCADA)
Yes
Patients diagnosed with
lung cancer or
mesothelioma first seen in
2011
356 (102%) of the
expected
Bowel Cancer (NBCA)
Partial
Patients diagnosed with
st
bowel cancer between 1
st
August 2010 and 31 July
2011
58 (14%) of the
expected - awaiting
cancer services
update for 2012
National Audits
ULHT
Participation
Reporting Period
Number and %
required
Head & Neck Cancer (DAHNO)
Yes
2012
110 % case
ascertainment not
known
Oesophago-Gastric Cancer (National O-G
Cancer Audit)
Yes
2012
140 % case
ascertainment not
known
Hip Fracture (National Hip Fracture
Database)
Yes
1 April 2011 – 31 March
2012
Fractured Neck of Femur (College of
Emergency Medicine)
Yes
1 August 2012- 30
November 2012
Falls & Bone Health
N/A
Trauma Audit Research Network (TARN)
Trauma
Yes
Cancer
Trauma
st
st
st
th
-
2012
791/812 (97.4%)
132/150 (88%)
Full audit did not
take place this year.
Pilot audit completed
by HQIP to review
and develop
standards for future
full audit
40%
Psychological Conditions
United Lincolnshire Hospitals Trust – Quality Account 2012/13
23
Prescribing in Mental Health Services
(POMH)
N/A
Not applicable to acute
trusts
N/A
National Audit of Schizophrenia (NAS)
N/A
Not applicable to acute
trusts
N/A
Blood Sample Collection (National
Comparative Audit of Blood Transfusion)
Yes
2012
49 (100%) of the
sample required
Medical Use of Blood (National
Comparative Audit of Blood Transfusion)
Yes
2012
28 (100%) of the
sample required
NCEPOD Alcohol Related Liver Disease
Yes
March 2012- March 2013
5/5 (100%)
NCEPOD Subarachnoid Haemorrhage
Yes
2012-2013
2/2 (100%)
Asthma Deaths (NRAD)
Yes
February 2012 -January
2013
Data still being
submitted
Blood Transfusion
Confidential Enquiries
Please note the following:
•
•
•
The benefit of participating in clinical audit is to provide some assurance that the
services delivered are safe and effective and that outcomes for patients are as
good as they possibly can be based on evidenced based practice and standards of
care. The percentage required by the terms of the audit could be a specific
number (for example 40 dementia cases) or it may be compared to Hospital
Episode Statistics (HES). This has been noted where available.
All clinical audits are disseminated by the Trust Clinical Governance department
and reviewed by the appropriate clinical teams. Local actions to improve are
exemplified in the table of after-audit actions below.
The participation is based on reports published during 2012/13 the data period
covered may cover previous years.
Glossary:
HQIP – Health Quality Improvement Partnership
SSNAP – Sentinel Stroke National Audit Project
EMAS - East Midlands Ambulance Service
United Lincolnshire Hospitals Trust – Quality Account 2012/13
24
After audit actions:
National Audit
Headline results and actions taken
Heart Failure
•
In reach heart failure nurse
MINAP (heart attack and Ischaemic
heart disease)
•
Eligible patients receiving primary percutaneous coronary
intervention via the catheter lab at Lincoln County. From April
2013 all eligible patients will be taken directly to the Catheter
Lab
•
Collaborative work with EMAS to review possible breaches in
the MI care pathway
•
Breaches discussed with clinicians identifying any training
needs
•
Several joint educational initiatives have been developed
•
Accreditation Trauma Unit Level 2 achieved
•
Data co-ordinators to be appointed to improve timely data and
upload to TARN
•
Improved trauma meetings to discuss case reviews and results
Hip Fracture
•
Improved time to theatre
Stroke
•
Improved compliance with NICE standards
•
24/7 Thrombolysis pan Trust
•
Improved time to CT scan
•
TIA clinics 7 days a week
•
Electronic TIA referral in place for GP’s, A&E and eye clinic
•
Data collected continuously via East Midlands Stroke Registry
(Dendrite) database upgraded March 2013 to allow upload of
data directly to SSNAP upload scheduled for April 2013
•
This is me patient leaflet
•
Work on-going to improve documentation of communication
with patients/carers
•
CQUIN to improve assessment on admission
•
Mandatory data submission
•
NJR co-ordinator provides quarterly reports of submissions
and provides support to improve data quality
TARN (Trauma)
Dementia
National Joint Registry (NJR)
United Lincolnshire Hospitals Trust – Quality Account 2012/13
25
•
Consultants able to access outcome data
•
Review of metal on metal hip replacements
Paediatric Diabetes
•
Good compliance with HbA1C
Epilepsy12
•
Good compliance with standards
Emergency use of Oxygen
•
Policy updated with revised oxygen prescription chart
Patient Reported Outcome Measures
(PROMs)
•
On-going recruitment of patients through pre-assessment
clinics to improve participation rate
•
Quarterly review of outcome data published by the NHS
Information Services
•
Finalised PROMs for patients recruited 2010-2011 published
th
15 August 2012. 92.2% of hip and 90.8% of knee patients
reported joint related improvements following their surgery.
86.5% of patients reported varicose vein improvement
following surgery.
•
Improve data submissions
Bowel cancer data
The reports of 134/284 local clinical audits were reviewed by United Lincolnshire Hospitals NHS Trust
between 1st April 2012 and 31st March 2013. The remaining audits are still active and will be
reviewed over the next few months.
Local Audit Speciality
Clinical Audits Registered on the Trust Clinical Audit
Database (number =284)
Accident & Emergency
15
Acute medicine
1
Anaesthetics
30
Breast surgery
1
Cardiology
14
Corporate
1
Dermatology
6
Diabetes/Endocrinology
11
Dietetics
7
Elderly Care
8
United Lincolnshire Hospitals Trust – Quality Account 2012/13
26
ENT
10
Gastroenterology
6
General Medicine
10
General Surgery
22
Gynaecology
1
Haematology
3
Intensive Care
3
Neonatal
15
Neurophysiology
1
Obstetrics & Gynaecology
24
Oncology
5
Ophthalmology
14
Oral Surgery
6
Orthodontics
1
Orthopaedics
14
Occupational Therapy
1
Paediatrics
18
Public & Patient Information
1
Pharmacy
4
Phlebotomy
1
Physiotherapy
5
Radiology
7
Rehabilitation
1
Respiratory
2
Rheumatology
1
Urology
13
Vascular
1
Total
United Lincolnshire Hospitals Trust – Quality Account 2012/13
284
27
Examples of actions taken locally:
Local Audit
Carotid Doppler - Grantham
Actions - Improvements
•
Early notification to stroke coordinator
•
Urgent request for CT
•
Staff training for both junior doctors
and nursing staff
•
Retained patient information standard
•
Patient information leaflets meet all
the standards required 100% achieved
following audit review and actions
•
Robust audit methodology noted by
external assessor
•
Risk stratification score included as
part of clerking document
•
Audit presented as poster at European
cardiology conference
•
Improved prescribing in line with
national clinical guidelines
•
Implementation of anti-embolic
stockings guideline and checklist for
nursing staff
Sepsis
•
Sepsis Care Bundle implemented
Clinical Record Keeping Doctors
•
Implementation of record keeping
audit tool
•
Actions for doctors locally to improve
by reviewing case notes and identifying
areas of improvement to colleagues
Patient Information Leaflets
Atrial Fibrillation
Prevention of Venous Thromboembolism
United Lincolnshire Hospitals Trust – Quality Account 2012/13
28
Participation in Clinical Research
The number of patients receiving NHS services provided or sub-contracted by United
Lincolnshire Hospitals NHS Trust in 2012/13 who were recruited during that period to
participate in research approved by a research ethics committee was 1253 against year-end
target of 1219 for portfolio studies. Total number of participants recruited for portfolio and
non-portfolio studies was 1703.
These patients/participants were recruited from a range of specialities and included patients
with cancer, stroke, diabetes, Dementia & Neurodegenerative diseases, paediatrics and a
number of other areas. The Trust is supporting trials from more specialities as compared to
2011/12. This increasing level of participation in clinical research demonstrates the United
Lincolnshire Hospitals NHS Trust’s commitment to improving the quality of care we offer
and to making our contribution to wider health improvement. In addition, by participating in
NIHR portfolio trials and recruiting patients, the Trust is playing an important role in
improving patient care and in developing new and innovative drugs, treatment and services.
The Trust has implemented findings of trials which has helped the Trust in improving patient
care and cost saving
The Trust is involved in conducting over 200 clinical research studies including studies in
follow up.
By the end of March 2013, for stroke Lincoln we recruited 44 patients against year-end
target of 40 and for Stroke Pilgrim we recruited 44 patients against year-end target of 40. In
case of cancer Randomised controlled trials, we are slightly below our targets; this was due
to lack of suitable studies and infrastructure.
Since the establishment of the Comprehensive Research Networks, the Trust has used the
national system for approving all studies (portfolio and non-portfolio) and risk assessments.
Of the 23 CSP studies given permission to start in 2012/13, the median time to approve
these studies was 24 days. More than half of the studies were established and managed
under national model agreements.
In 2012/13 the National Institute for Health Research (NHR) supported over 67 of these
studies through its research networks.
In the last three years, over 40 publications have resulted from our involvement in clinical
research, helping to improve patient outcomes and experience across the NHS.
The Lincolnshire Clinical Research Facility (LCRF) was HIGHLY COMMENDED in national
highly prestigious Health Service Journal Award for Research Culture category in November
2011. The LCRF has celebrated open day on 20th May, a large number of patients and staff
visited LCRF stalls in Lincoln, Pilgrim and Grantham Hospitals. The LCRF has been supporting
a large number of studies and the ULHT is among the top recruiting centre across the
United Lincolnshire Hospitals Trust – Quality Account 2012/13
29
country for a number of studies. The LCRF and The Research and Development Department
is committed to play an important role in follow following areas
•
•
•
•
•
•
•
To promote research and innovation
To develop a culture in which research is seen as integral to clinical practice
To support Business Units in developing specialist clinical services
To support all healthcare staff undertaking research
To support research activity by developing an infrastructure, which ensures all
research is carried out in accordance with the ‘NHS Research Governance
Framework’ and regulations.
To increase the number of staff within the Trust with skills in research
To work closely with R & D Departments within the other Lincolnshire health
providers to incrementally increase patients recruitment over the next five years
period
United Lincolnshire Hospitals Trust – Quality Account 2012/13
30
Commissioning for Quality and Innovation (CQUIN)
A proportion of United Lincolnshire Hospitals NHS Trust’s income in 2012/13 was
conditional on achieving quality improvement and innovation goals agreed between ULHT
and NHS Lincolnshire and any person or body they entered into a contract, agreement or
arrangement with for the provision of NHS services, through the Commissioning for Quality
and Innovation payment framework.
Further details of the agreed goals for 2012/13 and for the following 12 month period are
available on request from www.ulh.nhs.uk
The total amount of income in 2012/13 which was conditional upon achieving quality
improvement and innovation goals was £8.3 million and the payment received by the Trust
was £5.7 million. The table below illustrates those CQUINS achieved, partially achieved and
not achieved at this time.
No.
1a
1b
2
3a
3b
3c
4
Indicator
National Targets
Progress and achievements
Partial achievement
Achieved
Not achieved
Not achieved
Not achieved
Not achieved
Achieved
6
7a
7b
VTE Risk Assessment
VTE prophylaxis where clinically appropriate
Patient Experience: Improve responsiveness to personal needs of patients.
Dementia Screening: Patients aged 75 and over Screened within 72 hours
Dementia Screening: All those at risk have had a dementia risk assessment within 72 hours
Dementia Screening: All those at risk are referred for a specialist diagnosis
NHS Safety Thermometer: Collect data on pressure ulcers, falls, UTI and VTE
Regional Targets
Net Promoter: To demonstrate improvements in patient experience using the Net Promoter
score
Local Targets
Cancer: Reporting outcome of 2 week wait referral to GPs
Reduce number of patient ward moves
Daily ward all board round by senior decision maker
7c
Reduction in the number of hospital cancelled outpatient appointments
Partial achievement
8
Visual Planning Tool
9
10
11
13
Compliance with clinical trials in ARMD
Roll out of Ambulance ECS technology to allow the e- patient record
Robust data validation through audit and E learning master classes
Laparoscopic Cholecystectomy
14
Reduce ratio of outpatient follow ups (The aim is to improve from Lower quartile to median
performance or where above lower quartile to improve to 25th percentile performance.)
5
15
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Partial achievement
Achieved
1
2
Making Every Contact Count: To raise healthy lifestyle issues and offer advice
EMSCG Targets
Specialist services clinical dashboards
Increased access to Intensity Modulated Radiotherapy
3
Intravenous Chemotherapy and performance Status measurements
Achieved
4
6
Optimising Hepatitis C Treatment
Managing complications of chemotherapy
United Lincolnshire Hospitals Trust – Quality Account 2012/13
Achieved
Achieved
Achieved
Not achieved
31
Care Quality Commission (CQC) Statements
United Lincolnshire Hospitals NHS Trust is required to register with the Care Quality
Commission and its current registration status is full registration with minor impacts.
During 2012/13 the CQC visited Lincoln County Hospital in both April and
October/November 2012. At the visit in April they reviewed outcome 9 (management of
medicines) and judged it to be non-compliant. At the visit in October / November 8 out of
the 9 outcomes reviewed were judged to be compliant. This included outcome 9. The
current position at the end of March 2013 is that Lincoln County Hospital is compliant with
15 regulations/outcomes. There is still a minor impact relating to Regulation 22/Outcome
13 (Staffing).
A Remedial action plan to address this impact on patients is being implemented.
During 202/13 the CQC visited Pilgrim Hospital in both May and December 2012. At the visit
in May they reviewed outcome 9 (management of medicines ) and judged it to be noncompliant.. At the visit in December 8 out of the 10 outcomes reviewed were judged to be
compliant. This included outcome 9. The position at the end of March 2013 is that Pilgrim
Hospital is compliant with 14 regulations/outcomes. There is still a minor impact relating to
Regulation 9/Outcome 4 (Care and welfare of people who use services) and Regulation
22/Outcome 13 (Staffing)
Remedial action plans to address these impacts are being implemented.
In August 2012, the CQC visited County Hospital, Louth as part of a national targeted dignity
and nutrition inspection programme. The CQC reviewed 5 outcomes and they were all
judged to be compliant. The position at the end of March 2013 is that County Hospital Louth
is compliant with all 16 regulations/outcomes.
In February 2013 the CQC visited Grantham Hospital and 3 out of the 6 outcomes reviewed
were judged to be compliant. The position at the end of March 2013 is that Grantham
Hospital is compliant with 13 regulations/outcomes.. There are minor impacts relating to
Regulation 22/Outcome 13 (Staffing) and Regulation 23/Outcome 14 (Supporting workers).
Remedial action plans to address these impacts are being implemented.
The Trust has not participated in any special reviews by the CQC during 2012/13.
The position described above represents a significant change in the Trust’s compliance with
standards of care as judged by independent regulatory inspections. The tables below
indicate changes in compliance status for each major hospital site.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
32
Pilgrim Hospital Boston
Outcome
Feb – Nov 2011
Current position
Respecting & involving people who use services
Minor concerns
Compliant
Consent to care and treatment
Compliant
Compliant
Care and welfare of people who use services
Major concerns
Minor concerns
Meeting nutritional needs
Major concerns
Compliant
Co-operating with other providers
Moderate concerns
Compliant
Safeguarding people who use services from abuse
Minor concerns
Compliant
Cleanliness and infection control
Minor concerns
Compliant
Management of Medicines
Major concerns
Compliant
Safety and suitability of premises
Compliant
Compliant
Safety, availability and suitability of equipment
Compliant
Compliant
Requirements relating to workers
Moderate concerns
Compliant
Staffing
Moderate concerns
Minor concerns
Supporting workers
Moderate concerns
Compliant
Assessing and monitoring the level of service
provision
Complaints
Moderate concerns
Compliant
Moderate concerns
Compliant
Records
Moderate concerns
Compliant
Outcome
Feb – Nov 2011
Current position
Respecting & involving people who use services
Compliant
Compliant
Consent to care and treatment
Compliant
Compliant
Care and welfare of people who use services
Major concerns
Compliant
Meeting nutritional needs
Moderate concerns
Compliant
Co-operating with other providers
Moderate concerns
Compliant
Safeguarding people who use services from abuse
Compliant
Compliant
Cleanliness and infection control
Compliant
Compliant
Management of Medicines
Compliant
Compliant
Safety and suitability of premises
Moderate concerns
Compliant
Safety, availability and suitability of equipment
Compliant
Compliant
Requirements relating to workers
Compliant
Compliant
Staffing
Compliant
Minor concerns
Supporting workers
Major concerns
Compliant
Assessing and monitoring the level of service
provision
Complaints
Major concerns
Compliant
Moderate concerns
Compliant
Records
Minor concerns
Compliant
Lincoln County Hospital
Grantham District Hospital - first inspection (2013)
Outcome
Current position
Respecting & involving people who use services
Compliant
Consent to care and treatment
Compliant
Care and welfare of people who use services
Compliant
Meeting nutritional needs
Compliant
Co-operating with other providers
Compliant
Safeguarding people who use services from abuse
Compliant
United Lincolnshire Hospitals Trust – Quality Account 2012/13
33
Cleanliness and infection control
Compliant
Management of Medicines
Compliant
Safety and suitability of premises
Compliant
Safety, availability and suitability of equipment
Compliant
Requirements relating to workers
Compliant
Staffing
Minor concerns
Supporting workers
Minor concerns
Assessing and monitoring the level of service
provision
Complaints
Compliant
Records
Compliant
Compliant
United Lincolnshire Hospitals Trust – Quality Account 2012/13
34
Data quality
Data quality is an important element of safe, quality care at acute sites and is a continuing
focus for improvement. United Lincolnshire Hospitals NHS Trust will be taking the following
actions to improve data quality:
•
•
•
•
Process maps produced for patient flow through hospital (outpatients, day cases,
inpatients) and data quality reports identified at key stages to ensure any data input
errors are flagged earlier and highlighted to relevant teams for correction and any
training needs identified
Implementing actions identified by the 2012 Payment by Results Assurance Audit
(mainly around clinical coding, produced by the Audit Commission on behalf of NHS
Lincolnshire)
Review data quality function to ensure the team supports the needs of the Business
through a restructure of the department
Further implement and develop a data warehouse which will enable more timely
reporting of information and assist with data quality reporting throughout the
Business Units in the Trust
NHS Number and General Medical Practice Code validity
United Lincolnshire Hospitals Trust submitted records during April to March 2012/13 at the
Month 12 inclusion date to the Secondary Uses service for inclusion in the Hospital Episode
Statistics (HES), which are included in the latest published data. The percentage of records in
the published data:
•
which included the patient’s valid NHS number was: 99.7% for admitted patient care
(National performance 99.1%); 99.8% for outpatient care (National 99.3%); and
98.5% for accident and emergency care (National 94.9%).
•
which included the patient’s valid General Medical Practice Code was: 100.0% for
admitted patient care (National performance 99.9%); 100.0% for outpatient care
(National 99.7%); and 100.0% for accident and emergency care (National 99.4%).
Clinical coding error rate
United Lincolnshire Hospitals NHS Trust was subject to the Payment by Results clinical
coding audit by the Audit Commission during the 2012/13 reporting period. Previous audits
were based on one clinical area that was the focus of the audit with a couple of supporting
areas. This year, the focus was on two key areas for Admitted Patient Care, with A&E being
a new area audited. The performance of the Trust, measured using the error rate of the
number of spells affecting price, was 7.6% for admitted patient care. As mentioned above,
the Data Quality strategy will include accurate and comprehensive capture of information
within the clinical notes, which is then translated into clinical codes by the Coders.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
35
Clinical coding translates the medical terminology written by clinicians to describe a
patient’s diagnosis and treatment into standard recognised codes. The accuracy of this
coding is a fundamental indicator of the accuracy of the patient records.
Please note: these are technical errors of coding within patient records, not clinical errors in
terms of actual diagnosis.
Information Governance Toolkit attainment levels
The information quality and records management attainment levels assessed within
the Information Governance Toolkit provide an overall measure of the quality of data
systems, standards and processes within an organisation.
United Lincolnshire Hospitals NHS Trust score for April 2012 to March 2013 for information
quality and records management, assessed using the Information Governance toolkit, is
75%. The Trust has achieved full compliance with all 45 standards and is now fully
compliant with the Information Governance Statement of Compliance.
Reporting of harm to patients
Reporting of harm to patients and other significant incidents forms the basis for some
organisational learning and improvement initiatives. These data reflect Trust organisational
learning culture and are reported formally for the first time. It is subject to reliance on staff
reporting all incidents and include an element of local clinical judgement in the reported
figure. These data are forwarded from the Trust to the National Reporting and Learning
Service (NRLS) as follows:
Numerator: number of patient safety incidents resulting in severe harm or death, 117
incidents.
Denominator: number of patient safety indicators reported at Trust level through the NRLS,
10416 incidents).
The overall percentage of those judged internally to be severe or resulting in death is
therefore 1.12%.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
36
Data provided by the Health and Social Care Information Centre
The following data relating to national reporting requirements in the Quality Account are provided by the Health and Social Care Information
Centre.
Prescribed Information
Related NHS Outcomes
Framework Domain & who will
report on them
Indicator
1: Preventing People from
dying prematurely
2: Enhancing quality of life
for people with long-term
conditions
Acute trusts
“SHMI”
Indicator detail
Period
ULHT data obtained
National
Ranges: Best /
from Health and Social
average
Worse national
Care Information
(where
performance
Centre (HSCIC)
available)
The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to—
(a) the value and banding of the summary hospital-level mortality indicator (“SHMI”) for the trust for the reporting period; and
(b) the percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the trust for the reporting period. *The palliative care
indicator is a contextual indicator.
The SHMI is a ratio of
Oct 11 – Sept 12
Defined as
the observed deaths in
Value
109.85
100
71.08 / 125.59
a trust over a period of
OD Banding
2
1/3
time divided by the
expected number given
July 2011 – June 2012
NA
the characteristics of
Value
109.09
patients treated by that OD Banding
2
trust.
Patient deaths with
Percentage of deaths
Oct 11 – Sept 12
11.2% (11.18)
NA
0.3% is lowest
palliative care coded
reported in the SHMI
46.3% is highest
at either diagnosis or
indicator where the
July 2011 – June 2012
11.2% (11.22)
NA
specialty level
patient received
palliative care
The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the trust’s
patient reported outcome measures scores for—
(i)
groin hernia surgery,
(ii)
varicose vein surgery,
(iii)
hip replacement surgery, and
(iv)
knee replacement surgery, during the reporting period.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
37
Prescribed Information
Related NHS Outcomes
Framework Domain & who will
report on them
Indicator
Indicator detail
Period
3: Helping people to recover
from episodes of ill health or
following injury All acute
trusts
The trust’s patient
reported outcome
measures scores for—
(i) groin hernia
surgery,
(ii) varicose vein
surgery,
(iii) hip replacement
surgery, and
(iv) knee replacement
surgery.
Patient Reported
Outcome Measures
(PROMs) are a means of
collecting information
on the effectiveness of
care delivered to NHS
patients as perceived by
the patients
themselves.
Apr 10 – Mar 11
Apr 09 – Mar 10
ULHT data obtained
from Health and Social
Care Information
Centre (HSCIC)
Hernia – 0.078
V Vein – 0.114
Hip – 0.388
Knee – 0.298
National
average
(where
available)
Hernia – 0.085
V Vein – 0.091
Hip – 0.405
Knee – 0.298
Hernia – 0.068
V Vein – 0.054
Hip – 0.405
Knee – 0.302
Hernia – 0.082
V Vein – 0.094
Hip – 0.411
Knee – 0.294
Ranges: Best /
Worse national
performance
Hernia: 0.156 /
-0.020
V Vein: 0.155 /
-0.007
Hip – 0.503 /
0.234
Knee – 0.407 /
0.164
The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the
percentage of patients aged—
(i)
0 to 14; and
(ii)
15 or over, readmitted to a hospital which forms part of the trust within 28 days of being discharged from a hospital which forms part of the trust
during the reporting period.
3: Helping people to recover The percentage of
The percentage of
Apr 10 – Mar 11
(i) 8.43
(i) 10.15
7.08 / 12.39
from episodes of ill health or patients aged—
patients readmitted to a
(ii) 10.13%
(ii) 11.42
10.70 / 13.31
following injury All trusts
(i) 0 to 14; and
hospital which forms
(ii) 15 or over,
part of the trust within
readmitted to a
28 days of being
hospital which forms
discharged from a
part of the trust
hospital which forms
Apr 09 – Mar 10
(i) 8.47
(i) 10.18
within 28 days of
part of the trust during
(ii)
9.58%
(ii) 11.16
being discharged from the reporting period
a hospital
United Lincolnshire Hospitals Trust – Quality Account 2012/13
38
Prescribed Information
Related NHS Outcomes
Framework Domain & who will
report on them
Indicator
Indicator detail
Period
ULHT data obtained
National
Ranges: Best /
from Health and Social
average
Worse national
Care Information
(where
performance
Centre (HSCIC)
available)
The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the trust’s
responsiveness to the personal needs of its patients during the reporting period.
4: Ensuring that people
The trust’s
Average weighted score Apr 11 – Mar 12
64.2
67.4
85.0 / 56.5
have a positive experience
responsiveness to the of 5 questions relating
of care All acute trusts
personal needs of its
to responsiveness to
Apr 10 – Mar 11
66.2
67.3
patients
inpatients' personal
needs (Score out of 100) Apr 09 – Mar 10
64.5
66.7
The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the
percentage of staff employed by, or under contract to, the trust during the reporting period who would recommend the trust as a provider of care to their family
or friends.
4: Ensuring that people
The percentage of
Percentages who
Staff Survey - 2011
47%
60%
have a positive experience
staff employed by, or
agreed and who
(Agreed = 42% +
(Agreed = 49%
of care All trusts
under contract to, the strongly agreed with the
Strongly agreed = 5%)
+
trust during the
statement from the "b.
Strongly
reporting period who
If a friend or relative
agreed = 11%)
would recommend
needed treatment, I
HSCIC states that 2011
41% (40.464)
81.856
94.20 / 35.34
the trust as a provider would be happy with
is most up to date
(Average
of care to their family the standard of care
results, but the 2012
score for 4th
or friends
provided by this Trust"
survey results are in fact
quartile)
columns.
available
The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of
patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period.
5: Treating and caring for
The percentage of
Number of admissions
Apr 12 – June 12
Q1 – 89.9%
Q1 – 93.4%
people in a safe
patients who were
vs number of completed
environment and protecting
admitted to hospital
risk assessments
Jul 12 – Sept 12
Q2 – 91.4%
Q2 - 93.8%
them from avoidable harm
and who were risk
All acute trusts
assessed for venous
United Lincolnshire Hospitals Trust – Quality Account 2012/13
39
Prescribed Information
Related NHS Outcomes
Framework Domain & who will
report on them
Indicator
Indicator detail
thromboembolism
Period
ULHT data obtained
from Health and Social
Care Information
Centre (HSCIC)
Q3 – 91.1%
Oct 12 – Dec 12
National
average
(where
available)
Q3 - 94.1%
Ranges: Best /
Worse national
performance
100.0% / 84.6%
The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the rate per 100,000
bed days of cases of C.difficile infection reported within the trust amongst patients aged 2 or over during the reporting period.
5: Treating and caring for
The rate per 100,000
Apr 11 – Mar 12
17.6
21.8
0 / 51.6
people in a safe
bed days of cases of
environment and protecting
C.difficile infection
them from avoidable harm
reported within the
All acute trusts
trust amongst
Apr 10 – Mar 11
22.4
29.6
patients aged 2 or
over
The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the
number and, where available, rate of patient safety incidents reported within the trust during the reporting period, and the number and percentage of such
patient safety incidents that resulted in severe harm or death.
5: Treating and caring for
people in a safe
environment and protecting
them from avoidable harm
All trusts
The number and,
where available, rate
of patient safety
incidents reported
within the trust
during the reporting
period, and the
number and
percentage of such
patient safety
incidents that
resulted in severe
harm or death.
Patient safety incidents
reported to the National
Reporting and Learning
Service (NRLS) by
provider organisations
per 100,000 population.
Apr 12 – Sept 12
Oct 11 – Mar 12
NA
Severe harm = 38
(0.7%)
Death = 13 (0.2%)
5090 (reported)
6.2 (rate per 100
admissions)
NA
Severe harm / death =
57 (rate per 100
admissions of 0.1)
Commentary on these key indicators is presented overleaf.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
5203 (reported)
6.4 (rate per 100
admissions)
40
NA
LARGE ACUTE
TRUSTS ONLY
(based on rate)
1.99 / 13.61
0 (rate 0.00) /
144 (rate 0.18)
Indicator
Key factors
Actions
SHMI
ULHT considers that this data is
as described for the following
reasons: quality of clinical care,
the high level of end-of-life
admissions in the Trust and the
depth of coding of comorbidities
ULHT is taking the following
actions to improve this score
and so the quality of its
services, through our
Mortality Reduction plan
Patient deaths with palliative care coded
at either diagnosis or specialty level
ULHT considers that this data is
as described for the following
reasons: depth of coding of
palliative care.
ULHT is taking the following
actions to improve this score
and so the quality of its
services, through our
Mortality Reduction plan and
its coding guidance
The percentage of staff employed by, or
under contract to, the trust during the
reporting period who would recommend
the trust as a provider of care to their
family or friends
ULHT considers that this data is
as described for the following
reasons: staffing levels and
organisational culture
The percentage of patients who were
admitted to hospital and who were risk
assessed for venous thromboembolism
ULHT considers that this data is
as described for the following
reasons: improving reliability in
risk assessment
ULHT is taking the following
actions to improve this score
and so the quality of its
services, through our
organisational develop
strategy and staffing review
ULHT is taking the following
actions to improve this score
and so the quality of its
services, through a continued
focus on reliability
The rate per 100,000 bed days of cases of
C.difficile infection reported within the
trust amongst patients aged 2 or over
ULHT considers that this data is
as described for the following
reasons: strong performance in
infection control and
prevention
ULHT is taking the following
actions to improve this score
and so the quality of its
services, through a continued
focus on infection
management
The number and, where available, rate of
patient safety incidents reported within
the trust during the reporting period, and
the number and percentage of such
patient safety incidents that resulted in
severe harm or death.
ULHT considers that this data is
as described for the following
reasons: good reporting
behaviour in staff
ULHT is taking the following
actions to improve this score
and so the quality of its
services, continuing emphasis
on organisational learning
United Lincolnshire Hospitals Trust – Quality Account 2012/13
41
Part 3
Review of quality performance
This section is where we set out information relating to the quality of services that we
provide. It includes details of how we organise to manage quality and safety, a review of last
years’ priority areas, external review and assurance of our quality and an overview of
performance against selected metrics, national targets and indicators.
Organisational arrangements and initiatives to embed quality
To address our goals in quality, we have developed a Trust Quality strategy outlining our
strategic ambitions. These rest upon four principles:
•
•
•
•
Patient safety
Clinical effectiveness
Excellence in experience
Continuous improvement and cultural change
Our goals and strategy have been developed to take into account the needs of the Trust and
its stakeholders including service users, commissioners, partners and our valued staff. The
principle areas of quality shown above are therefore drawn from national guidance, but also
from our own ambition to continually improve quality for our patients. A summary of our
plans and key initiatives is provided below; if you would like further information in any area,
please contact communications@ulh.nhs.uk.
Patient Safety
The safety of those within our care is the foundation of quality and continues to be our Trust
quality priority. During 2012/13 our patient safety team has continued to train staff in the
principles of safety through nurse preceptorship and junior doctor education programmes,
as well as participating in targeted training for specific areas including neonatology,
paediatrics and medication safety. In December 2012, we hosted a conference at Pilgrim
Hospital Boston attended by over 100 senior clinicians and managers which focused on
sharing good practice in clinical areas and included workshops in minimising human error
and key human factors such as situational awareness, communication and decision-making.
Key safety initiatives are described below.
Safety Express Plus
Safety Express is a continuing campaign focusing on the reduction of four patient harms
with potentially devastating effect on adult inpatients: falls, pressure ulcers, VTE and
United Lincolnshire Hospitals Trust – Quality Account 2012/13
42
catheter-acquired urinary tract infections. We launched the programme in 2011/12 and
have continued it throughout 2012/13. Key data to assess our progress on this programme
is provided by a national point prevalence audit, where all adult in=patients are checked
every month for harm. During 2012/13 we have been able to bring about a reduction in
pressure ulcers and have consistently assessed 89% - 93% of our patients as being “harmfree” at any point.
The Safety and Quality Dashboard
The reliability of fundamental ward care processes is the most important aspect of patient
care. At ULHT we have developed and consistently employed a “dashboard” to provide
immediate measures of process reliability, which we call the “Safety and Quality Dashboard”
or SQD. These data are publically displayed on all adult in-patient wards and used by ward
teams to guide improvement activities. There are more than 50 indicators on the SQD,
covering the key areas of:
•
•
•
•
•
•
•
•
•
•
Patient observations
Patient medications
Patient dignity
Falls
VTE
Pressure Ulcers
Urinary catheter management
Peripheral catheter management
Nutrition
DNACPR (Do Not Attempt Cardio-Pulmonary Resuscitation; formerly DNAR)
Data are gathered by independent data co-ordinators and provided to each ward, matron
and the Patient Safety team in order to identify improvement priorities and provide
assurance to the Trust. During the period April 2012-March 2013, significant improvements
were identified in most of these indicators, indicating the development of a growing culture
of reliability across all sites. Overall process reliability, measured as an average of all
indicators, has improved from 55% at the inception of the programme, to 79% in March
2013. We have recently introduced a similar dashboard to assess and develop robust safety
in medication, and during 2013/14 we will continue to build reliability in ward processes, as
well as extending our use of safety dashboards to other areas of risk, including medical
processes.
“Be assured” programme
The objective assessment of quality and safety is an essential element in assuring and
developing safe, quality care, and the Trust values the critical input we receive from external
regulatory visits. These, however, take place relatively infrequently. Recognising this, the
Trust has established a programme of internally managed compliance visits termed “Be
Assured”. Each ward or patient area is visited by a review team consisting of senior
United Lincolnshire Hospitals Trust – Quality Account 2012/13
43
clinicians, clinical specialists and managers who assess compliance with Care Quality
Commission essential standards. This process is supported by a detailed methodology and
manual, and in general consists of:
•
•
•
•
In-depth review of at least five complete sets of patient notes
Interviews with all suitable patients and relatives on the ward/area
Interviews with ward leaders and junior staff
Reviews of key process reliability metrics from the SQD.
This programme provides a deep review of compliance and leads to improvement actions at
ward level, supported by the clinical governance team. During 2012/13, we reviewed a total
of 37 patient areas, representing 60% of key locations.
Patient Safety Leadership Walkrounds
The Trust continues to carry out Patient Safety Leadership Walkrounds, as part of an
ambition to ensure consistent “ward to board” contact with the front line of clinical care.
Executive and non-executive directors visit wards and theatres in the Trust to review safety
performance, listen to the safety concerns of the ward staff, identify principle risks and
share their standards and expectations of safety with local teams.
Patient Experience
The Trust is committed to listening to and understanding patients’ experiences whilst
receiving care and treatment within our services and has a comprehensive Patient
Experience Strategy and workplan to enable us to do this. Under the Director of Nursing’s
executive leadership the Deputy Director of Nursing leads the work programme for patient
experience and progress against action plans is monitored through the Patient Experience
Committee which has a wide membership including patient representatives and external
agencies such as Lincolnshire Local Involvement Network and Lincolnshire Carers
Partnership.
Current activity includes building on existing projects such as the “Friends and Family” test,
real time patient surveys, reading and responding to feedback left online at Patient Opinion
and NHS Choices and a range of smaller projects such as noise at night, asking questions in
outpatients and providing discharge information. Major work for the coming year includes
working with carers having developed and launched a Carers Policy and will include a
dedicated carers survey to ensure we understand the experience of carers as well as
patients. We have developed reporting frameworks for wards and services to know how
patients feel about the care within their areas and a public facing feedback process so our
patients and visitors know what patients have said about their experience and what we are
doing as a result to continuously effect improvements in our care and service delivery. The
United Lincolnshire Hospitals Trust – Quality Account 2012/13
44
Trust Board will continue to receive monthly reports on a range of patient experience
indicators and hear a patient story each month at the Board meetings; reflecting the real
commitment to ensure patients voices are heard and included in all that we do.
Effectiveness of Care
We continue to focus on measures that allow us to monitor the quality and safety of the
care that we provide – and further our quality goal of continuous improvement. We have
reviewed our quality targets and agreed a set of indicators that form a key part of
monitoring the quality of care.
These indicators of quality and effectiveness include:
•
•
•
•
•
•
•
•
•
•
•
•
•
HSMR (Hospital standardised mortality ratio)
Prevention of venous thromboembolism
Reduction in pressure ulcers
CQUINs (national, regional and local)
Trauma - fracture neck of femur patients operated on within 24 hours
Infection prevention
The number of complaints we receive
Response to complaints within agreed time scale
Level of complaints reopened
Care of mothers and babies
Care of stroke patients
Patient reported outcome measures (PROMS)
Care of cardiac patients
Performance data for these indicators are reviewed monthly, discussed at speciality and
directorate meeting monitored systematically by the Trust Board.
Monitoring and learning from clinical experience
Incident review and dissemination
When things go wrong for our patients, as they occasionally do in all Trusts and clinical
settings, effective clinical governance requires us to learn. To ensure that key lessons are
identified, learned and shared across the organisation we have established a high-level
monitoring function, supplemented by a dissemination process. In practical terms, an
Incident Review Group, chaired by the Medical Director, considers each serious incident in
turn through reviewing the investigation report, the learning points contained, and also the
quality of the investigation conducted. Common themes are identified, aggregated and then
United Lincolnshire Hospitals Trust – Quality Account 2012/13
45
analysed over time in order to identify, for example, the key factors underpinning npressure
ulcers, falls, infections and clinical errors.
The dissemination process at ULHT begins with the Sharing Lessons Learned forum, where
incidents and any other concerns are discussed and reviewed by a multidisciplinary team. As
well as building a shared understanding of events or processes that affect patient safety, the
forum also identifies the key recipients of the information and ensures through a tracking
log that key lessons are shared. Information is shared directly with key personnel and also
through a Trust-wide Patient Safety Newsletter highlighting significant lessons, risks and
opportunities for improvement.
Clinical Systems Analysis
We have continued to employ a robust development of the “standard” NHS incident
analysis methodology termed “Clinical Systems Analysis”. An effective learning system
requires two essential elements: the understanding of and response to individual incidents,
where local factors affect patient care; and the understanding of and response to Trust-wide
factors that impact on patient care more generally. Unlike most “root cause analysis”
systems, Clinical Systems Analysis enables the systematic collection of contextual risk factor
information so that data can be aggregated across many investigations. In this way, the
most significant common factors in safety incidents, including human factors, can be
pinpointed for improvement.
Innovation and improvement – Transforming Our Services
Transformation
The trust needs to save approx. £20 million each year as part of delivering the NHS £20
billion savings target. In 2011/12, the trust launched its Transformation Programme to
support quality and safety improvements for patients admitted as emergencies (urgent
care) and patients admitted for elective procedures (planned care). By improving quality
and safety we will reduce our costs.
In 2012/13 we have been working to achieve the priority aspirational standards that patient
representatives, our clinical staff and managers helped to develop by focusing on a few key
areas
•
Reducing length of stay
•
Improving theatre utilisation
•
Improving outpatients
Reducing length of stay - What have we achieved?
United Lincolnshire Hospitals Trust – Quality Account 2012/13
46
1. Implemented a daily review by a senior doctor of every patient 5 days a week and of all
urgent patients 7 days a week
2. We have successfully implemented a Plan for Every Patient visual planning tool on all of our
medical wards across the trust. This has helped to remove unnecessary delays to patient
care and reduced length of stay by an average of 10%.
3. We have increased the times and days we offer key diagnostic services so that they are
available when patients need them
4. We continue to develop A&E services with GPs and other health community organisations
that ensure that patients receive a coordinated service and the right care to meet their
needs.
5. We have commenced Ambulatory Care at Pilgrim Hospital
Why have we done this?
Senior review – achieving a review of every patient every day by a senior doctor was one of the key
priority urgent care standards. We know a daily review by a senior doctor means plans are checked
regularly, unnecessary delays are reduced and patients who deteriorate are treated much sooner,
improving outcomes. The Academy of Medical Royal Colleges has published standards for senior
reviews which we are working to implement. A senior doctor now completes a ward round or
undertakes a board round (using the Plan for Every Patient board).
Plan for Every Patient - each health professional looking after patients has their own records where
they record the detailed plans of care but on a busy ward its difficult to coordinate the plans of
doctors, nurses, physiotherapists, occupational therapists, dieticians, social workers and other staff.
Patients have complex medical problems and making sure that each test, procedure or action that is
needed to progress the patients care is taken at the right time , without unnecessary delay is also
difficult. Plan for Every Patient helps the ward team set out a visual plan for each patient so that
staff can see what is needed and when. The plan is checked every day by all of the key staff looking
after the patients.
Diagnostics – achieving 7 day diagnostics services was one of the priority urgent care and planned
care standards. Diagnostics has improved the service to 6 days for most diagnostic tests with urgent
Endoscopy lists 7 days at the Lincoln and Pilgrim sites.
A&E – we know that we admit more patients who attend our A&E departments than other trusts. To
improve this we are working with GPs, community nurses and social care staff so that patients who
attend A&E and who do not need admission have the right services provided for them to maintain
them in the community. We have commenced implementation of Ambulatory Care to make sure
that patients who do not need to be admitted have the right care for their condition.
Ambulatory Care – It is nationally recognised that for some medical presentations patients are best
treated in a “same day emergency care setting” which is called ambulatory care. We have improved
United Lincolnshire Hospitals Trust – Quality Account 2012/13
47
our performance for some of the ambulatory conditions and in some cases are in the best 25% of
hospitals in the country.
We now plan to:
• Implement Plan for Every Patient on all of our Orthopaedic Wards across the trust
•
Use Plan for Every Patient for senior doctors daily check of patients progress against their
plan, when a full ward round is not planned.
•
Extend more diagnostic services to 7 day working where it is needed for our patients
•
Work to further integrate A&E services , including extending the clinical space in A&E at
Lincoln to co-locate the Out of Hours service and increase the number of cubicles.
•
Complete the implementation of Ambulatory Care at Pilgrim Hospital and roll it out to
Lincoln and Grantham Hospitals .
Theatres Utilisation - What have we achieved?
1. We have successfully increased our theatre utilisation from approx. 70% to over 85% across
our 4 sites as at February 2013.
2. We have successful trialled changes to one of our planned procedures pathways and
reduced the referral to treatment time for patients with Colorectal conditions from 21
weeks to 9 weeks.
3. We have developed a centralised pre assessment service on the Lincoln site.
4. We have opened a dedicated Day Surgery Unit on the Lincoln site.
Why have we done this?
Achieving 90% theatre utilisation was one of the priority planned care standards. Theatre utilisation
is key to making effective use of limited theatre capacity. We have achieved this by reviewing the
colorectal 18 week patient pathway and reviewing the way we plan patients on our theatre lists.
We reviewed the 18 week Colorectal pathway and discovered it was actually 21 weeks long! By
focusing on what adds value to the patient and working with clinical staff we were able to eliminate
many of the delays.
Achieving a centralised pre assessment service at Lincoln Hospital was one of the priority planned
care standards. The new service will include access to a consultant anaesthetist for patients with
complex health problems.
Achieving a dedicated Surgical Day Case Unit was one of the priority planned care standards. The
Unit opened in September at Lincoln Hospital and now treats 200 patients a month.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
48
We now plan to:
• Further improve theatre utilisation by maximising the time available to operate
•
Learn lessons from the Colorectal pathway trial and make improvements permanent prior to
rolling out to other planned care pathways
•
Further improve pre-assessment services by ensuring that we have the right number of
nursing staff with the right skills to meet patient needs on each site
•
Further increase the number of day cases that are undertaken on the Surgical Day Unit
Outpatients - What have we achieved?
1. We have reduced the number of patients requiring follow up in outpatients in some of our
specialties
2. We have implemented self-check in kiosks on all of our sites to allow patients to book in
more quickly
Why have we done this?
A number of planned care standards were set to improve outpatients and we have more work to do
to achieve them. We have appointed a project lead to work with our Cardiology teams to improve
outpatients so that we can learn lessons and then roll them out to other specialty teams.
We know we have a higher number of patients that are followed after having surgery or being in
hospital up than other trusts. Following up patients after being in hospital is important but does not
always need to be done in outpatients. It can be safely done at the patients GP or in the community
or if it needs to be done in outpatients it may be that another health professional e.g. a nurse or
physiotherapist might provide the service.
We now plan to:
• Reduce the number of patients that are followed up in all specialties during 2013/14
•
Improve outpatients working with Cardiology teams
•
Commence a project at Grantham to review outpatient services
Focus on Improvements and Innovation
There have been a lot of other improvements in the trust. These are just some of some of the
improvements that we have made over the last year.
Vascular Services
United Lincolnshire Hospitals Trust – Quality Account 2012/13
49
Pilgrim hospital has become the county’s specialised vascular centre. This is surgery for conditions of
the arteries and veins, such as aneurysms, thrombosis and varicose veins. We have developed stateof-the-art outpatient and vascular diagnostics laboratory facility. The vascular laboratory has new
high-tech vascular scanners and other equipment such as ankle brachial pressure monitoring system
and treadmill. We have recruited additional dedicated Clinical Vascular Scientists and appointed
Vascular Acute Care Practitioners who will see patients through their journeys from outpatients to
the ward and theatres providing some continuity for patients.
Stroke
We have invested £250,000 to develop our stroke facilities at Pilgrim Hospital. The new stroke unit
has 28 beds and has been refurbished with a range of new medical equipment and therapy services
have been incorporated into the ward area to ensure that patients receive a stroke service seven
days a week. The new unit consists of three areas: a four bedded hyper-acute area to receive direct
admissions from A & E, a 12 bedded acute/rehabilitation area and a 12 bedded rehabilitation area.
Stroke trackers have been appointed to Lincoln Hospital to ensure that all patients are admitted to
the stroke unit within four hours.
We have implemented seven day therapy services for stroke patients. These services, which include
physiotherapy, occupational therapy, dietetics and speech and language therapy, have been
extended to complement the development of new stroke units in Lincoln and at Boston’s Pilgrim
Hospital and to help supply rehabilitation to the 10 stroke beds at Grantham. Evidence shows that
since recruitment of the additional staff in January these standards have significantly improved with
all the targets being achieved in recent months.
X Ray
We have invested in new X Ray facilities at Louth, Skegness and Grantham. Grantham hospital is the
first site in United Lincolnshire Hospitals NHS Trust to have a fully digital radiology service. The trust
has invested £750,000 for two new digital x-ray rooms- one of which will carry out all x-ray
examinations and the other will be a state-of-the-art hybrid room catering for both x-rays and
fluoroscopy work, which uses live images to diagnose or treat patients. All of the new equipment in
both rooms will be digital, producing instant images and will replace the previous computerised xray equipment which required more processing time.
Cancer Services
We have implemented a dedicated occupational therapy service for oncology and haematology
outpatients at Lincoln County Hospital. This new service will provide occupational therapy help
patients who are receiving active radiotherapy or chemotherapy, those who are due to have elective
surgery and who need symptom management.
Maternity
We have completed a £600,000 upgrade of the Maternity Department at Pilgrim Hospital including
includes disabled toilets and bathrooms on each floor along with replacement windows and flooring
and general refurbishment. The buildings received criticism last year from hospital regulators and
United Lincolnshire Hospitals Trust – Quality Account 2012/13
50
the recent work has taken place to ensure the hospital can provide an environment in which to
deliver consistently high standards of care.
Investment in Consultant Doctors
The trust has funded £554,000 at Pilgrim Hospital to recruit four new consultant physicians, three
acute care practitioners and support staff. Among the problems the new staff will improve will
include:
•
Improving patient flow through hospitals which leads to frequent shortages of beds and
patients staying in hospitals longer than they need
•
Patients being kept in the wrong area of a hospital due to a lack of beds
•
Improving the quality of care
•
Cancelled operations
•
Overuse of bank and agency staff
•
Improving the learning experience of junior doctors
Hip Fracture Improvements
Over the past year, teams at Pilgrim Hospital, Boston have revolutionised the care of patients who
have hip fractures, by improving assessment, the speed at which patients are taken to theatre for
surgery and after care. This has resulted in the hospital meeting its target to operate on all hip
fracture patients within 36 hours of arrival in A&E. Mortality for hip fracture patients at the hospital
has reduced and length of stay for these patients is significantly down
Respiratory Improvements
Pilgrim Hospital’s respiratory department has been transformed so that patients referred to it for
suspected lung cancer can now have a one stop service where all their diagnostic tests done at a
clinic on their first visit to hospital.
Awards
The trust was shortlisted in the Education and Training in Patient Safety category of the national
Health Service Journal Awards this year. The nomination is for the Releasing Time to Improve Patient
Safety project, which has been working to release the time of medical staff to focus on
improvements in patient safety across Lincolnshire’s hospitals, including setting up a Junior Doctor
Patient Safety Forum at Lincoln County Hospital.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
51
United Lincolnshire Hospitals Trust – Quality Account 2012/13
52
Supporting our workforce to deliver high quality care
Workforce
Our HR Strategy 2011-2014 was developed through an engagement process to provide an
overall direction for how we recruit, retain, develop, reward and motivate our staff. There
were 3 main areas of focus for the plan:
1. Developing our structures, policies and our procedures so that they better enable
our staff to deliver high quality safe patient care
2. Developing the skills, capability, behaviours that will impact on both staff and the
patient experience and make ULHT somewhere people want to work and be treated
3. Improving the way that we engage with our stakeholders and staff
Developing our Systems and Processes
Over the course of the year we went through a process of better understanding the impact
of our system, policies and processes and prioritising the changes to those that would make
the biggest impact first. An example of this is in absence management. We undertook a
detailed analysis to help us understand where absence was the biggest problem, how that
impacted on our ability to deliver patient care and then set about introducing a suite of
interventions to improve its management. We introduced a case management team to
better support line managers, we introduced new training our HR staff and line managers
and we improved our Occupational Health support to staff and line managers. A year on we
have had excellent feedback from our staff and managers and have extended the approach
and at the same time have developed a Health and Wellbeing strategy to identify how we
can make improvements to the workplace to keep people at work and support them in their
return to work.
A significant achievement over the course of the year was the development of our ‘business
partnering’ approach to how Human Resources and Line Managers work together to the
benefit of our services and patient care. We introduced new roles and capability and our
feedback from managers is that they feel better supported in their role as advocates and
managers for staff.
Developing our Culture and our People
We recognised that in order to make a sustainable change to the improvements to patient
care we needed to invest in our people and in developing the right culture and behaviours.
We undertook an extensive engagement exercise through which to understand what it feels
to work and manage in ULHT and map out the things we needed to do in order to develop a
patient centred culture.
As a result of this work we have introduced an Organisational Development Sub Committee
of the Trust Board that is responsible for taking forward the recommendations from this
exercise and developing the organisation to deliver high quality safe patient care. We have
also developed an Organisational Development Strategy and a senior leadership Programme
that will go live the first quarter of 2013/2014. The organisational development strategy
demonstrates a significant organisational ambition to developing our culture through:
United Lincolnshire Hospitals Trust – Quality Account 2012/13
53
•
•
•
•
•
•
Developing a new mission, vision and values to align all of our strategies, processes
and development to
Developing an engagement and communications strategy to get people more
involved in the business of ULHT
Developing a staff and leadership charter to set out what people can expect
Developing a first line manager programme to better equip those new into
management
Introducing a new appraisal system to introduce an integrated process and one
which provides high quality and productive conversations
Introducing integrated talent management processes to ensure that all our staff feel
they can make the best contribution possible and are recognised for doing so
Appraisal
Appraisal is critical to the development and performance of individuals so that they can
undertake their roles effectively. We have improved our processes and provide detailed
information for managers so that they can ensure that they can plan their appraisals
continuously.
We have introduced new processes for dealing with medical appraisals and ensured greater
validation of the quality and compliance of these appraisals recognising that good medical
appraisals will directly impact on good clinical outcomes for patients. We have increased our
compliance rate to over 70% over the last quarter of 2012/2013.
Clinical Leadership Skills
We have a well-established programme of professional development such as the Trust
Leadership Programme for all senior leaders and the Post Graduate Certificate and Diploma
in Health Management and Leadership. The learning incorporates a blend of classroom, elearning, action learning sets, courses and projects. Our Leadership Programme was codesigned and delivered with Executive Directors and focussed on the development of
strategic clinical leaders who are committed to improving the quality of the patient
experience and to improve the Trusts ability to meet current and future organisational
challenges.
Other supporting programmes have included Management Essentials, Health Care Support
Worker, NVQ’s and Assistant Practitioner Foundation Degree.
We have also introduced a clinical and leadership forum for our matrons and our ward
leaders which have the sponsorship and involvement of our Director of Nursing and our
Deputy Director’s.
ULHT is part of a Lincolnshire public sector coaching network and has a number of fully
qualified coaches who offer their support in-house and to the public sector partners. ULHT
staff have the option to receive coaching from an external coach who can offer a different
perspective.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
54
Occupational Health
The Trust has a continuing focus on demonstrating its commitment to improving the health
of patients by supporting the health and wellbeing of our staff. Occupational Health aims to
have a more focused and concerted approach to work age and health and towards reducing
the effects of unhealthy behaviours in the work force we support. Be proactive in tackling
the causes of ill health – both work related and lifestyle related The Trust is working towards
a system of rapid access for all its employees to help staff stay in work during illness or
return to work after illness. In place at present are accesses to Occupational Health,
Physiotherapy and Counselling Services including a number of resources for managing work
related stress.
We have also introduced an integrated IT management system for Occupational Health to
ensure a more effective and efficient service to staff and managers, this also links with
surrounding Trusts allowing us to network and work towards the NHS Health at Work
recommendations on future consolidation of NHS Occupational Health Services.
Resourcing
We have made significant changes to the way that we recruit in order to ensure that our
practices are legally compliant and focused on attracting the right staff with the right skills,
experience and behaviours who share our passion and values for delivering high quality safe
patient care. As an example we have incorporated mandatory standard dignity in care and
safeguarding questions into our selection processes.
We have had positive results in our processes and compliance acknowledged in feedback
received during the NHSLA, UK Border Agency and CQC audits that have taken place.
In order to support our managers we have implemented bespoke recruitment and selection
training, introduced specialist international and UK recruitment campaigns. We made a
significant improvement to our junior doctor rotations enabling a smooth and effective
transition and safeguarding patients at all times.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
55
Review of 2012/13 improvement priorities
For 2012/13, we selected six priorities for improvement, each linked to one of the key
quality domains of safety, effectiveness or patient experience. As with the priorities
identified for 2013/14, these were identified through discussion, review of performance in
key areas of national focus, staff feedback and patient needs. In the following sections we
review our progress during the year for:
•
•
•
•
•
•
Further reducing our Hospital Standardised Mortality Rate (HSMR)
Continuing to meet the nutritional needs of our patients
Further reducing healthcare associated infections
Continuing to develop reliability in risk assessment and prophylaxis for venous
thrombo-embolism
Continuing to improve our timeliness in responding to complaints
Improving the safe discharge of our patients
United Lincolnshire Hospitals Trust – Quality Account 2012/13
56
Priority 1 – reducing our Hospital Standardised Mortality Rate (HSMR)
What are mortality indicators?
Mortality indicators are used to try to establish whether hospital mortality is higher or lower
than average. They cannot and do not claim to establish whether any particular death or
group of deaths was avoidable. There are two in common use: Hospital Standardised
Mortality Rate (HSMR) and Standardised Hospital Mortality Indicator (SHMI). Though they
are based on similar principles and methodologies, there are some key differences, which
we explain below.
HSMR compares the levels of deaths of patients in hospitals (hospital mortality) in different
years, or between different groups of patients/ailments in the same year. So as to create a
measure that allows mortality to be compared between differing hospitals, the method for
calculating HSMR takes account of differences in the patients we see (the case mix) and also
for variables such as age; ethnicity; admission source and type; level of deprivation; period
of admission; and co-morbidity (the presence of other disorders as opposed to the primary
reason for admission to hospital).
SMHI is a similar measure which is based on a statistical model developed from national
hospitals data. It calculates for each hospital how many deaths would be expected to occur
if they were like the national average. The model takes into account a number of factors
such as differences in age, sex, diagnosis, type of admission and other diseases (comorbidity). This figure is then compared with the number of deaths that did occur in order
to identify “outliers” where mortality was higher than expected.
For both measures, if the same number of deaths occurred as expected this ratio will be 1,
although usually we multiply by 100 to make the figures easier to understand, so an
“average” hospital will have a SHMI of around 100. A SHMI of greater than 100 implies more
deaths occurred than predicted by the model. Unlike HSMR, SHMI includes deaths 30 days
after discharge and does not take into account palliative care.
How should mortality indicators be used?
HSMR and SHMI are not intended to be punitive but to assist organisations to monitor their
mortality. At the Francis Inquiry, Professor Jarman of Imperial College made it clear that it is
not possible to calculate the exact number of deaths that would have been avoidable, nor to
identify avoidable incidents because those tasks would require expert review of all the
relevant case notes. The statistics can only be signposts to areas for further inquiry. He also
stated that it is not possible to conclude, without more information than the HSMR alone,
that a high outlier is attributable to poor care. Nor is it possible to say that any specific
number or proportion of deaths was from an avoidable cause .
United Lincolnshire Hospitals Trust – Quality Account 2012/13
57
Mortality indicators therefore serve as pointers for clinicians to examine particular sites,
diagnostic groups or directorates in order to determine – through further analysis – whether
there are issues with the quality and safety of care. These analyses are routinely carried out
when our data indicate higher than expected levels of mortality.
What have we achieved?
Hospital mortality, as measured by the comparative index “HSMR” continues to be a cause
for concern and a major focus for the Trust. The most recent available data covering the
period 2012/13 is shown below.
HSMR for the most recent month (January 2013) is 99.9 and is within the expectations of
the predictive model used by Dr Foster Intelligence – the commercial organisation which
provides these data.. The rolling 12 month figure for HSMR is 104.0, which is also
statistically “as expected”. However, once the data for 2012/13 has been retrospectively
“re-based” to take into account the overall national changes in death rates, the HSMR is
expected to rise to 109. This will be statistically higher than average.
Historically, United Lincolnshire Hospitals Trust has exhibited a mortality rate higher than
expected. Table 1 shows Trust HSMR for the period 2006/7 to 2011/12. Current HSMR (for
the period April 2012 – November 2012) stands at 104 though it will be “rebased” by Dr
United Lincolnshire Hospitals Trust – Quality Account 2012/13
58
Foster Intelligence in September 2013 to take into account changes in national
performance.
Current status
The most recent HSMR data are shown below.
Year
2006/7
2007/8
HSMR
106
113
2008/9
2009/10
2010/11
113
106
113
2011/12 2012/13 (year
to Jan 2013)
111
104
Table 1 – HMSR to current year
While the overall trend for HSMR reflects a fall in mortality, this area remains a key concern
for the Trust.
Key improvement initiatives
ULHT is one of 14 Trusts with high relative mortality under review by the Department of
Health. The review makes no assumptions regarding contributing factors in mortality and is
intended to be supportive. Many factors contribute to mortality figures and are the subject
of ongoing analysis and improvement planning. These include:
•
•
•
•
•
Standards of clinical care, including the reliability of key processes
Learning from patient events including mortality, through systematic review
Managing admissions and palliative care
Working with community partners in healthcare to ensure compassionate and
robust end-of-life care planning
Local demographic factors such as our aging population.
What this means for patients
Quality of patient care depends primarily on reliable care processes – doing the right thing
for the patient at the right time. To a large degree, the factors within the control of the
Trust that influence mortality rates centre on this area – the quality of care – rather than
demography and patterns of admission, however critical these may be. We will therefore
continue to build on our strong record in measuring and improving our quality of care,
continue to learn from mortality through systematic review and develop integrated planning
for patients with community partners.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
59
Priority 2 – Continuing to meet the nutritional needs of our patients
What have we achieved?
The Trust Nutritional Steering Committee has oversight and improvement responsibilities
and continues to meet regularly. Site-based Nutrition Focus Groups have been established
to improve communication and local implementation of policies. This is improving local
initiatives and the groups include housekeepers, clinicians and catering in order to establish
strong consensual actions to improve nutritional care.
Our key risk assessment tool used to identify and trigger management of at-risk patients is
the Malnutrition Universal Screening Tool, or MUST. This has been updated as part of the
new nursing assessment booklet. And now includes guidance for immediate referral to
Dieticians if patients are identified as being at risk.
Current status
Key process reliability metrics for our performance in nutritional care are part of the Safety
and Quality Dashboard, which provides metrics directly related to front line patient care,
assessed independently each month on adult in-patient wards. The figure below shows our
achievements in 2012/13 compared to the previous year.
Improvements in nutritional care
2011/12 to 2012/13
100.0
90.0
80.0
70.0
60.0
2011/12
50.0
2012/13
40.0
30.0
20.0
Nutrition Nutrition MUSTNutrition MUST
Patients
Nutrition care Food record
demographics completed on
updated
weighed on plans activated commenced if
correct
admission
weekly
admission &
if required
required
weekly
Dietician
referral if
required
Improvements in nutritional care
These data show continuing improvements:
•
Over 90% of our patients have a correct risk assessment for nutrition
United Lincolnshire Hospitals Trust – Quality Account 2012/13
60
•
•
•
Over 90% of our patients are weighed weekly
Care plan utilisation has increased by 21%
Referrals to dieticians has increased by over 21%
Key improvement initiatives
The National Descriptors for Altered Consistency, a key initiative in personalised care
delivery, was launched across the Trust on 4th Feb 2012. This means we are now using the
nationally recommended system for describing altered consistency food for patients with
dysphagia. This work was done jointly with S&LT and Catering and there are now new
menus across the Trust to provide patients with dysphagia a suitable menu choice. They
now have a choice of menu items. The Trust is buying in commercially prepared items
specially designed to meet the descriptors.
Staff training is focused on nurses through the preceptorship programme, healthcare
support workers, Dysphagia Trained Nurses, and continuing ward-based training. We also
conduct regular teaching sessions for medical students and routinely deliver sessions on
feeding tube care for trained staff.
The Protected Mealtimes Policy has been updated and a re-launch is planned for this year.
The Nutritional Alert System has been piloted and roll-out planned. In addition, the
Volunteer Mealtime Companion scheme being undertaken as a research project in
conjunction with the University of Lincoln.
What does this mean for patients?
Managing nutrition is a key element of patient care, especially in caring for elderly and other
vulnerable patients. Our improvements in caring for these critical groups demonstrates that
nutritional care has become increasingly safe and reliable and that our patients are reliably
monitored, assessed and treated on our wards.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
61
Priority 3 – reducing healthcare associated infections
What have we achieved?
In 2012/13, we have performed on trajectory for MRSA bacteraemia, with six cases
identified against our target of six. However, Clostridium difficile colitis performance was
more challenging: the Trust identified 76 cases against a target of 61. As a Trust, we
recognise that infection remains a national priority area and a key concern when patients
are considering the quality of care that they receive.
Current status
The Trust has continued to work hard to manage and reduce infections. Performance is
shown in the figure below.
Infection prevention 2012/13
80
70
60
Total C. difficile infections
2012/13 (post 3 days)
*revised target
50
40
Total MRSA bacteraemias
2012/13 (post 48 hours
30
20
10
0
Target
Actual
Preventing infections
Key improvement initiatives
During 2013/14, we will maintain the substantial focus already in place to reduce the
infections that cause harm to patients. This will include a focus on:
•
•
•
•
•
•
•
Epidemiological surveillance
Decontamination
Decontamination of the environment
Invasive devices
Training
Prevention and control of outbreaks
Collaboration with external organisations
United Lincolnshire Hospitals Trust – Quality Account 2012/13
62
What this means for patients
Patients can be assured that we will continue our progress in the prevention of healthcare
associated infections. We will continue to focus on infection prevention as an improvement
objective and we have already begun to extend our work to include infections other than
MRSA and C. difficile as part of our approach.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
63
Priority 4 – continuing to develop reliability in risk assessment and
prophylaxis for venous thromboembolism (VTE)
What have we achieved?
This important national issue has been a major focus of quality improvement at the Trust.
During 2012/13 we have addressed two key issues: the reliability of risk assessment for
those patients most vulnerable to dangerous blood clots and the provision of appropriate
prophylaxis when at-risk patients are identified. VTE risk assessment is carried out on wards
by doctors and both this and the provision of appropriate preventative measures has
improved significantly during the year.
Current status
Our work in this area has enabled us to achieve our key target of risk-assessing more than
90% of patients. From zero risk assessment in 2010 (when the national work in this area
was initiated) to 75% in 2010/11 and 86% in 2011/12, we now routinely achieve more than
90%, as shown below for 2012/13 by month .
Reliability of risk assessment for VTE
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Risk assessment for VTE
Having identified patients at risk, preventing harm depends on medical interventions –
usually appropriate anti-coagulation medications and/or physical barriers to blood clots
such as anti-embolic stockings. As with risk assessment, Trust reliability has improved in this
area, as shown below.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
64
VTE prophylaxis provision
92.00%
90.00%
88.00%
86.00%
84.00%
82.00%
80.00%
78.00%
76.00%
74.00%
72.00%
Prophylaxis for VTE
Key improvement initiatives
We continue to maintain high performance in this area through:
•
•
Public displays of reliability metrics on each ward – feedback to clinicians and
patients
Senior medical leadership through Trust Medical Directors and Deputy Medical
Directors
What this means for patients
Reliability in identifying and managing risks of blood clots is now at a higher level than ever
before and continues to improve, building further assurance of patient safety.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
65
Priority 5 – improved handling of complaints
What have we achieved?
During 2012/13, the Trust has experienced an overall increase in the number of complaints
and concerns received, often associated with an increase in media coverage. In previous
year, the Trust had significant difficulties in responding to complaints in a timely manner,
with performances often falling short of our aspirations. The key measure in this important
area is the percentage of complaints responded to within our internally agreed timescales.
In 2010/11, we frequently achieved this in only 20-30% of cases; during 2011/12 we were
able to increase this to 70-90%, an achievement we continued into 2012/13, though recent
performance has declined slightly.
Current status
Performance during 2012/13 is shown below.
% Complaints reply within agreed timescales
100
90
80
70
60
50
40
30
20
10
0
Responding to complaints
Key improvement initiatives
•
•
•
We continue improving our processes by reviewing and auditing the complaints
process, particularly where complainants are not satisfied during our first
attempts to resolve their complaint. Reopened complaints are now a key
measure and form part of regular inspection at Trust Quality and Safety
Committee meetings
We continue to strengthen working relationships by providing support from the
Customer Care Team for operational management teams.
We analyse both the issues presented and the findings of our investigations to
enable targeted actions to be taken.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
66
What this means for patients
Feedback from patients and carers is vital to refining our services and strengthening our
quality and safety. Prompt handling of complaints has improved significantly over recent
years, providing a responsive service to the public and ensuring that key learnings from
patient care are incorporated into our change programmes.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
67
Priority 6 – improving the safe discharge of our patients
What have we achieved?
Safe discharge of patients with appropriate communication to patients and partners in
healthcare affects readmission rates, length of stay, health outcomes and cost to patients
and healthcare providers. Our key measure for the reliability is the “Electronic Discharge
Document” or eDD. During 2011/12, approximately 50% our patients received an eDD
within 24 hours of discharge. We have made significant improvements in this during
2012/13, with a mean figure for 2012/13 of 68.53%.
Current status
Annual monthly performance is shown below.
Monthly performance in electronic discharge documents with 24 hours
of discharge
74.00%
72.00%
70.00%
68.00%
66.00%
64.00%
62.00%
60.00%
58.00%
eDD performance
Key improvement initiatives
Our initiatives focus on:
• The use of a multi-disciplinary discharge plan for use by all staff supporting patient
discharge in ULHT
• In particularly complex discharges, identification of a lead professional to manage
the process
• Implementation of Multi-disciplinary Team Board rounds to focus on discharge
planning
• Reviewing the need for a dedicated discharge planning team at ward level linked to
• complex elderly patients
United Lincolnshire Hospitals Trust – Quality Account 2012/13
68
What this means for patients
Continuity of care between settings – in this case between community care and acute care –
is essential for patient safety. The reliable communication of changes in care, of changes in
medication regimes and of test results is a key requirement. We have improved our
performance in this area though we recognise clearly that more work is needed to achieve
our aspirations for quality in care.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
69
External regulation and assurance
Care Quality Commission (CQC)
The Trust is required to register with the Care Quality Commission and its current
registration status is full registration with concerns.
NHS Litigation Risk Management Standards (Acute)
The Trust was last assessed in January 2013 at Level 1. There is an intention to achieve Level
2 and the final decision on this will be based on the evidence built over this year. A final
decision made in quarter 3, 2013/14.
Clinical Negligence Scheme for Trusts ULHT Maternity Services
The Clinical Negligence Scheme for Trusts (CNST) standards and assessment process are
designed to provide a framework to focus effective risk management activities in order to
deliver quality improvements in organisational governance, patient care and the safety of
patients.
ULHT currently has CNST Level 1. There are 5 standards, each containing 10 criteria. Within
each criterion there are minimum requirements expected to be met. Standards change
yearly and usually contain new criteria to achieve. New standards have just been published
for 2012/13, current guidelines will need to be amended in line with new recommendations.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
70
Quality Overview
Quality overview section
a) Performance of ULHT against selected measures & b) National targets at a glance
Topic
Dr Fosters
Dr Fosters
Dr Fosters
Dr Fosters
Indicator
Hospital Standardised Mortality Ratio
Hospital Standardised Mortality Ratio - 12 month
rolling
Readmissions by diagnosis
Readmission by procedure
Care pathway Fractured Neck Of Femur - Patients operated on
/ CQUIN
within 24 hours
Fractured Neck Of Femur - Patients operated on
Care pathway
within 36 hours
Care pathway Fractured Neck Of Femur - Patients operated on
/ CQUIN
within 48 hours
MINAP
Call to needle time within 60 mins
MINAP
Door to needle time within 30 mins
MINAP
Call to balloon time within 150 mins
MINAP
Door to balloon time within 90 mins
PROMs
Orthopaedic - Hips (Oxford score)
PROMs
Orthopaedic - Knees (Oxford score)
PROMs
Surgery - Groin Hernia (EQ-5D score)
PROMs
Surgery - Varicose Veins (Aberdeen score)
CQUIN
Grade 3 or 4 pressure ulcers (accumulative)
Never events
Target
April 2011 - March
2012
April 2012 - March
2013
Most recent
performance
(available as of
start of May 2013)
90
101.7
102.8
99.8
90
NA
NA
104
90
90
94.7
94.1
97.1
99.7
96.1
96.6
72.5%
52.36%
74.34%
65.33%
80%
65.25%
84.40%
81.33%
95%
79.75%
92.20%
93.33%
68%
75%
NA
NA
Better than
national average
Better than
national average
Better than
national average
Better than
national average
57.30%
72.70%
NA
NA
56.8%
70.0%
94.1%
96.6%
59.2%
66.6%
74%
94%
95.7%
95.5%
95.5%
92.1%
88.9%
88.9%
50.6%
51.0%
51.0%
82.0%
76.9%
76.9%
0
55
NA
52
4
52
0
Stroke
% High risk TIA seen and scanned within 24 hours
60%
22%
57%
63%
Stroke
% Patients who spend 90% of time on stroke unit
80%
43%
78%
78%
Stroke
Stroke
% Access to a scan within 24 hours
% Access to a scan within 60 mins
For eligible patients; % Thrombolysed within 4.5
hours*
Outcome of death from stroke inpatient stay
% of patients admitted to Stroke Unit within 4
hours of hospital arrival
100%
50%
94%
22%
98%
51%
98%
57%
12%
93%
92%
100%
Stroke
Stroke
Stroke
NA
17%
19%
14%
90%
23%
72%
67%
Progress level 3
80%
8.7%
12.0%
90
Level 2 achieved
70.61%
8.81%
14.33%
84.9
Level 3 in progress
70.19%
8.93%
14.69%
68.5
Level 3 in progress
68.79%
8.29%
15.42%
47.9
Maternity
Maternity
Maternity
Maternity
Maternity
Baby friendly standards progress
Breastfeeding initiation rates
Elective caesarean section rate
Emergency caesarean section rate
Obstetric trauma WITHOUT delivery by instrument
Maternity
Obstetric trauma WITH delivery by instrument
90
69.4
69.9
64.7
C-Diff
MRSA
E coli
MSSA
Incidence of Clostridium difficile (accumulative)
Incidence of MRSA bacteraemia (accumulative)
Incidence of e coli (accumulative)
Incidence of MSSA bacteraemia (accumulative)
61
6
96
24
74
4
NA
NA
76
6
89
26
76
6
89
26
80%
44%
72%
66%
505 / year
756
739
739
Complaints
Complaints
Proportion of complaints responded to within
agreed timescale
Total number of formal complaints received
(accumulative)
Notes
Most recent performance figures - These figures are the most recent monthly (March) or quarterly (January 2013 to March 2013) figures available.
Variation applies to Obstetric trauma Oct - Dec 12; HSMR January 13 and Feb 12 - Jan 13 for 12 month rolling.
Dr Fosters indicators -These indicators show how well the trust is performing when compared to the national benchmark of 100%. So whilst a performance
of lower than 100 is better than the national average, the Trust are aiming for 90 as to ensure we are striving for continuous improvement. The trust uses a
colour coding system so we can identify areas where improvement is needed. A score of over 100 is red, 91 to 99 is amber and 90 or below is green.
Please note annual performance is April 2012 to January 2013 for HSMR and obstetric trauma, and Apr 12 to Oct 12 for readmissions.
Stroke: For eligible patients; % Thrombolysed within 4.5 hours* - Performance changed during the year following NICE publishing TA264, which
recommended thrombolysis within 4.5 hours, rather than the previous recommendation of within 3 hours. This has increased the number of eligible
patients from 14 in 11/12 to 66 in 12/13.
PROMS - Data collection for 12/13 is ongoing. 11/12 is a more complete dataset and considered more reliable figure for representation.
United Lincolnshire Hospitals Trust – Quality Account 2012/13
71
ULHT Performance at a Glance - March 2013
Achieve
Year to
date
Total time in A&E: 4 hours or less
95%
95.22%
Referral to treatment times milestones - Admitted
90%
90.87%
Referral to treatment times milestones - Admitted - Median Wait
11.1 weeks
11.58
*
Referral to treatment times milestones - Admitted - Median Wait (95th Percentile)
23.0 weeks
21.71
*
95%
95.10%
Referral to treatment times milestones - Non-Admitted - Median Wait
6.6 weeks
6.14
*
Referral to treatment times milestones - Non-Admitted - Median Wait (95th Percentile)
18.3 weeks
17.96
*
92%
92.41%
Referral to treatment times milestones - Incompletes - Median Wait
7.2 weeks
5.95
*
Referral to treatment times milestones - Incompletes - Median Wait (95th Percentile)
28 weeks
17.86
*
1%
0.96%
Indicator
Referral to treatment times milestones - Non-Admitted
Referral to treatment times milestones - Incompletes
Waiting times for diagnostic tests
Number of inpatients waiting longer than the 26 week standard
0.03%
Number of outpatients waiting longer than the 13 week standard
0.03%
19
0.03%
954
0.65%
Maximum waiting time of two weeks from urgent GP referral to first outpatient
appointment for all urgent suspect cancer referrals
93%
94.68%
2 week standard for non-suspected (symptomatic) breast referrals
93%
91.28%
Maximum waiting time of 31 days from decision to treat to start of treatment extended
to cover all cancer treatments
96%
97.26%
31 day subsequent drug treatments
98%
98.12%
31 day subsequent surgery treatments
94%
95.57%
31 day subsequent radiotherapy treatments
94%
91.40%
Maximum waiting time of 62 days from all referrals to treatment for all cancers
85%
83.25%
62 day standard from screening programmes
90%
95.63%
62 day consultant upgrade
85%
83.33%
(Cancelled ops) Number of patients whose operation was cancelled, by the hospital, for
non clinical reasons, on the day of or after admission
(Cancelled ops) Not treated within 28 days. (Breach)
Delayed transfers of care
United Lincolnshire Hospitals Trust – Quality Account 2012/13
0.80%
5%
3.50%
1179
1.59%
313
26.55%
2.76%
72
MRSA Bacteraemia (Post 48 Hours)
6
6
Clostridium difficile (Post 72 Hours)
61
76
Thrombolysis - 60 minute call to needle time
68%
58.14%
Waiting times for Rapid Access Chest Pain Clinic (2wk Wait)
98%
100%
Mixed Sex Accommodation
0
0
VTE
90%
90.54%
eDD
90%
68.5%
Complaints completed within timescale
80%
66%
89
104
HSMR (YTD based on rolling 12 months not Apr-date)
SHMI (Jul-11 - Jun-12)
Fractured neck of femur
109.09
24 Hours
70%
74.3%
48 Hours
95%
92.2%
Indicators highlighted have data older than current month
* Performance is for most recent month available not year to date
United Lincolnshire Hospitals Trust – Quality Account 2012/13
73
*
Stakeholder comments
NHS Lincolnshire West Clinical Commissioning Group (Lead Commissioner)
Thank you for the opportunity to review the Trust Quality Account. It is a well written, open
and transparent account of quality achievements for 2012/13 and quality aspirations for
2013/14. The CCG congratulates the Trust staff on the depth and scope of work undertaken
to address previous quality of care concerns. It is clear that much progress has been made,
as evidenced by the most recent CQC compliance inspections to all the Trust sites – which
are testament to the hard work being undertaken by staff. As acknowledged within the
Quality Account there is no complacency and it is good to see the emphasis on the need for
continual improvement in the quality of care.
The priority areas of improvement highlighted by the Trust for 2013/14 are fully endorsed
by the CCG and will build on the improvements already made by the Trust in these areas
during 2012/13. Where relevant the CCG is committed to working in partnership with the
Trust and other partners to bring about improvement in these areas eg. in end of life care,
antibiotic prescribing by general practice, increasing community and social care pathways,
etc.
Continued improvement also needs to be maintained in the resourcing of VTE prevention,
diagnosis and treatment with regard to manpower and efficient data collection systems.
This area is quite rightly a continued focus for improvement driven nationally. A key area
for improvement for 2013/14 must be ensuring all areas are staffed appropriately as
highlighted within the recent CQC reports. Again the CCG recognises the scope of work
undertaken to review staffing levels, recruit and retain staff during 2012/13 and the
commitment by the Trust to invest substantially in this area over the next couple of years in
terms of extra staff and organisational development.
The amount of research undertaken within the Trust and the mature and developing
research culture is to be applauded particularly as maintained throughout times of
challenge.
The CCG also supports completely steps being taken by the Trust to improve data quality,
clinical records and clinical record safekeeping. Improvements in these areas are perceived
to be essential by the CCG as is drive from within the Trust to implement electronic patient
records.
Particular initiatives recognised by the CCG as very good practice are the ‘Always Events’,
the ‘Be assured’ programme of internal compliance visits and the aggregation of learning
from incidents. Also the Trust’s continued commitment to sustain and improve measures to
United Lincolnshire Hospitals Trust – Quality Account 2012/13
74
actively seek out, listen and give a timely response to the patient and ‘carer’ voice is
essential.
In summary the CCG congratulates all the Trust staff on the progress and many
achievements evidenced within the Quality Account. The CCG fully supports the priority
areas identified for continued improvement and wherever possible is committed to work in
partnership with the Trust to aid achievement of these priorities and indeed any other
initiatives that will improve the quality of care our patients receive across care settings.
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Health Scrutiny Committee for Lincolnshire and Healthwatch Lincolnshire.
Statement on United Lincolnshire Hospitals NHS Trust’s Quality Account for
2012/13
This statement has been jointly prepared by the Health Scrutiny Committee for Lincolnshire
and Healthwatch Lincolnshire.
Review of Progress on Priorities for 2012-13
The Health Scrutiny Committee for Lincolnshire and Lincolnshire Healthwatch strongly
supported Priority 1 (Reduction Hospital Mortality) for 2012-13, so the reduction in the
level of the Hospital Standardised Mortality Ratio for 2012-13 is welcomed and the
improvements and initiatives that have been put in place are acknowledged.
Priority 2 (Meeting the Nutritional Needs of Patients) was also strongly supported last year,
and the improvements and initiatives in this regard are acknowledged. We approve of the
principle of protected meal times, but we would suggest some flexibility, as relatives can
sometimes help patients eat their meals and we also recognise the contribution that
volunteers can make. The challenge of meeting the nutritional needs of elderly frail
patients will continue and the importance of selecting the best menu options for elderly frail
patients should not be overlooked.
For Priority 3 (Reducing Healthcare Associated Infections), it is not clear why the target for
clostridium difficile infections was revised from 61 to 76 during the course of the year. We
recognise the reason for this priority being carried forward into 2013-14.
The improvements in relation to Priority 4 (Risk Assessment and Prophylaxis for Venous
Thromboembolism [VTE]) are acknowledged.
Last year, in relation to Priority 5 (Improved Complaint Handling), we stressed the
importance of informing the public about the standards and timescales for responding to
complaints. We would like to reiterate these comments, as patients and their relatives need
to have the confidence in the complaints system. It is important for all NHS organisations to
have in place arrangements to learn from their complaints.
We would have liked to have seen more detail on the progress with Priority 6 (Improving
Discharge of Patients), in particular on how the key improvement initiatives listed have
actually improved the level of service for patients, in particular elderly frail patients.
Priorities for 2013-14
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The Health Scrutiny Committee for Lincolnshire and Lincolnshire Healthwatch support the
Trust's five priorities for 2013-14.
•
•
•
•
•
The inclusion of Priority 1 (Reducing Hospital Mortality) is strongly supported. The
outcomes of the national review of mortality, expected in July 2013, are awaited and
will determine whether there is any evidence of actual unavoidable deaths in the
Trust's hospitals.
In relation to Priority 2 (Reducing Healthcare Associated Infections), the Health
Scrutiny Committee for Lincolnshire and Lincolnshire Healthwatch believe that the
targets for Clostridium Difficile and MRSA should not be revised during the course of
the year, but should be set at a maximum of 61 and six cases respectively.
Whilst the Health Scrutiny Committee for Lincolnshire and Lincolnshire Healthwatch
support Priority 3 (Eliminating Avoidable Pressure Ulcers), they are not completely
satisfied that the proposed aims and goals will necessarily achieve this priority.
For Priority 4 (Safe Discharge of Patients), the Health Scrutiny Committee for
Lincolnshire and Lincolnshire Healthwatch we would like to see evidence of a
stronger working relationship with Adult Social Care, to ensure that patients are
discharged appropriately to their place of residence.
Priority 5 (Senior Daily Review) is supported and will improve performance with
Priority 4.
Transformation Programme
Senior managers from the Trust have presented information and answered questions on
several occasions in the last year at the Health Scrutiny Committee on the transformation
programme. The achievements of the transformation programme are reflected in the
Innovation and Improvement – Transforming Our Services section of the Quality Account.
We support the Trust's aspirations and achievements to date in reducing the length of stay;
improving theatre utilisation; and improving outpatient services.
Pressures on Accident and Emergency
We are aware of pressures on the Trust's Accident and Emergency Departments, and we will
be looking to the Trust to continue working with commissioners to see how these pressures
can be reduced, for example, by emphasising alternatives such as Out Of Hours GP services
and the NHS 111 Service.
Conclusion
The Health Scrutiny Committee for Lincolnshire and Lincolnshire Healthwatch are pleased to
have had an opportunity to make a statement on the Quality Account, and congratulate the
Trust on the progress and achievements in the last year, but there remains much to be
done.
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Patient Council
The Patient Council welcomes the opportunity to comment on the Quality Account. Clearly
there have been improvements made over a number of areas. The Patient Council
particularly welcomes the commitment to further improve communication issues and to
increase performance in relation to the EDD.
Carol Mander
Patient Council
22.5.2013
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Appendix: Governance Statement 2012/13
United Lincolnshire Hospitals NHS Trust
Governance Statement 2012/13
Scope of responsibility
The Board is accountable for internal control. As Accountable Officer, and Chief Executive of
this Board, I have responsibility for maintaining a sound system of internal control that
supports the achievement of the organisation’s policies, aims and objectives. I also have
responsibility for safeguarding the public funds and the organisation’s assets for which I am
personally responsible, in accordance with the responsibilities assigned to me. I am also
responsible for ensuring that the organisation is administered prudently and economically
and that resources are applied efficiently and effectively. I acknowledge my responsibilities
as set out in the Accountable Officer Memorandum which sets out my responsibilities of
propriety and regulation of expenditure, and for putting in place effective management
systems which safeguard public funds and allow for the keeping of proper accounts.
The Trust is accountable for the delivery of its patient services through the contract it has
with its commissioners, the main commissioner being NHS Lincolnshire. The regulatory
framework within which it is working is that of the Strategic Health Authority ( NHS
Midlands and East) being responsible for the performance management of NHS
Lincolnshire, who hold the Trust to account through the contract. The Trust reports through
NHS Midlands and East and the Department of Health on performance against national
objectives.
The governance framework of the organisation
The system of internal control is designed to manage risk to a reasonable level rather than
to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only
provide reasonable and not absolute assurance of effectiveness. The governance and
system of internal control of the organisations is based on an ongoing process designed to:
•
•
identify and prioritise the risks to the achievement of the organisation’s policies,
aims and objectives,
evaluate the likelihood of those risks being realised and the impact should they be
realised, and to manage them efficiently, effectively and economically.
The system of internal control has been in place in United Lincolnshire Hospitals NHS Trust
for the year ended 31 March 2013 and up to the date of approval of the annual report and
accounts.
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Trust Board and Committee Structure
The Trust Board meets on a monthly basis and consists of a Chairman, 5 voting Executive
Directors, including the Chief Executive and 5 Non Executive Directors. The Director of
Operations, Director of Facilities, Director of Human Resources and Head of Governance
also attend the Board meetings. The Board focusses on strategic issues, whilst also
receiving assurances in relation to the organisational performance. The Trust is continuing
to progress its application for Foundation Trust status, and as part of this process has
completed a self assessment against the Board Governance Assurance Framework. This
process has identified areas where the Boards effectiveness could be further developed.
The Board is compliant with the Corporate Governance Code.
Supporting Committee Structures
To support the Trust Board in carrying out its duties effectively, committees reporting to the
Board are formally established. The remit of these committees was reviewed during the
year to ensure robust governance and assurance. Each committee receives reports as
outlined within their terms of reference and work programme, and provides an exception
report to the Trust Board after each meeting.
The key committees for governance and assurance are as follows:
Audit Committee - delegated to approve the annual accounts on behalf of the board and
provide assurance in relation to , Internal and external audit, counterfraud and security
management, financial reporting, integrated governance, risk management and internal
control, and the annual governance statement.
Governance Committee – to provide assurance that robust governance and risk
management arrangements are in place within the Trust and that they are working
effectively. This is achieved through consideration of the risk management arrangements
and risk management report, scrutiny of the Board Assurance Framework and the key
organisational risks. Exception reports from the Health and Safety Committee, Information
Governance Committee and Quality and Safety Committee are considered by the
Governance Committee.
Both Audit and Governance Committees have produced highlight reports following each
meeting to report to the Trust Board. Covering those areas where assurance has been
sought, received, and where further action to gain assurance was required.
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Meeting
Trust Board
Audit Committee
Governance Committee
Attendance rate for voting members
76%
80%
67%
In addition the Board is supported by the Remuneration Committee, Charitable Funds
Committee, Estates Committee and Foundation Trust Programme Board.
Risk assessment
Overall responsibility for risk management rests with all members of the Board. The
Medical Director has an explicit responsibility for the risk management function within the
organisation. The Director of Finance has specific responsibility for financial risks within the
Trust. There is a defined structure for the management and ownership of governance,
through the risk register and assurance framework which is regularly monitored in the
Board committees and at Trust Board level. The Trust operates and maintains a Board
approved Risk Management Strategy that identifies the levels of accountability and
responsibility for all staff within the organisation.
Risk Management training commences at induction with further training in risk
management provided through the annual mandatory training programme. The training
reinforces individuals’ accountabilities with respect to risk management and enables staff to
assess and manage risks within their sphere of responsibility. More specialised risk
management training is provided to staff in accordance with their role within the
organisation
The organisation also has a sharing lessons learned framework which facilitates the
dissemination of good practice across the organisation. The principle of sharing lessons
learned is simple, in that key lessons to be learned from all of the various clinical
governance activities and performance reviews are identified and presented. The sharing
lessons learned forum considers learning reports and ensures that lessons to be learned are
shared across the organisation.
Trust Major Risks during 2012/13
During 2012/13 the Trust took a range of actions to continuously scrutinise and assure
against the major risks facing the Trust.
The most significant risks identified during 2012/13 were
• Failure to fully comply with CQC outcomes across all sites
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•
•
•
Failure to deliver the financial plan and challenging cost improvement programme
and meet the financial pressures faced across the NHS.
Failure to provide accessible services with minimal waits to meet minimum national
standards
Failure to achieve improved effectiveness and efficiencies through service
transformation.
The United Lincolnshire Hospitals NHS Trust score for April 2012 to March 2013 for
information quality and records management, assessed using the Information Governance
toolkit, is 75%. The Trust has achieved full compliance with all 45 standards and is IGSoC
fully compliant. United Lincolnshire Hospitals NHS Trust has an information assurance
management policy to manage and control risks in relation to data security. Risks relating to
information and data security have been recorded in the Trust risk register where necessary
and the Governance Committee has reviewed during the year the assurances provided that
risks were being mitigated. Information risk management is reviewed and monitored by the
Trust Information Governance Committee which meets monthly and reports directly to the
Governance Committee.
The risk and control framework
Managing risk is the responsibility of all employees and not just the role of specialists,
managers or the Trust Board. All employees are responsible for identifying, reducing and
eliminating risk where possible. A key element of the Trust’s Risk Management strategy is
the integration of risk management into both the strategic and routine operational decision
making processes within the Trust. The strategy is designed for prevention and deterrence
of risks, and the Board are committed to minimising risk through the use of the risk register
and Board Assurance Framework.
Policies are in place which encourage staff to report adverse incidents and near misses in
order to minimise risk and take action to prevent recurrence. This message is reinforced
through the risk management strategy.
An organisational risk register is maintained which comprises information from all key
managers who have identified the main risks in their area of work. Risk assessments
contribute to the Trust’s risk register and encompass both clinical and non clinical risks.
Risks are reviewed in respect of all reports presented to the Trust Board, along with the
relevant equality impact assessment.
During 2012/13 the Trust has continued its work to create strong governance arrangements,
suitable for its application for Foundation Trust status. Specifically:
• An established and experienced senior management structure
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•
•
•
•
A robust information governance framework in place
A review of Standing orders, Standing Financial Instructions and Scheme of
Delegation.
NHSLA accreditation
Compliance with NHS Protect directives.
The Board is responsible for setting the organisation's aims and objectives and ensuring that
an Assurance Framework identifies the principal risks to the organisation meeting these
aims and objectives, as well as confirming the key controls in place to manage these risks.
The Board Assurance Framework identifies the source of independent assurance in relation
to each objective and risk. The framework is dynamic to reflect changes in priorities and
developments in the external environment. It is a strategic management tool to support the
annual governance statement, not designed to show every risk, but to focus attention on
those which are most significant.
The Governance Committee and Audit Committee assess the adequacy of the Assurance
Framework on behalf of the Accountable Officer and the Board, and advise the Board in
relation to the systems, processes and controls in place in order to have co-ordinated and
effective risk mitigation in achieving the Trust’s objectives. This enables the Board to
discharge its responsibilities for governance and understand the balance of clinical,
operational and financial risk.
Throughout 2012/13, the Board has identified and monitored against key objectives within
its Board Assurance Framework. The controls and assurances in relation to the objectives’
risks were received by the Board during the year. The framework identified gaps in control
for some financial, operational and clinical measures and the Trust has taken and continues
to take remedial action to address them.
The Trust has involved the Patient Council in managing the risks that affect the Trust. They
are represented on the Trust Board, the Governance Committee and Quality and Safety
Committees and carry out periodic inspections within the Trust.
The Trust continues to put in place an adequately resourced plan of work for the Local
Counter Fraud Specialist which includes proactive deterrence and prevention of fraud work.
Review of the effectiveness of risk management and internal control
As Accountable Officer, I have responsibility for reviewing the effectiveness of the system of
internal control. My review is informed in a number of ways. The Head of Internal Audit
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provides me with an opinion on the overall arrangements for gaining assurance through the
Assurance Framework and on the controls reviewed as part of Internal Audit’s work The
Overall Head of Internal Audit Opinion gave significant assurance. Executive managers
within the organisation who have responsibility for the development and maintenance of
the system of internal control provide me with assurance. The Assurance Framework itself
provides me with evidence that the effectiveness of controls that manage the risks to the
organisation achieving its principal objectives have been reviewed. My review is also
informed by the Audit Commission, clinical audit, the Royal Colleges and the Multi
professional Dean’s visits, Dr Foster analysis and the Care Quality Commission.
I have been advised on the implications of the result of my review of the effectiveness of the
system of internal control by the Board, Audit Committee and Governance Committee. A
plan to address weaknesses and ensure continuous improvement of the system is in place.
The Internal Audit reviews undertaken during 2012/13 led to the Head of Internal Audit
providing a significant assurance opinion on the system of internal control in the Trust. In
reaching this opinion the review assessed :
•
•
the design and operation of the assurance framework and supporting processes and
the status or preparedness of the organisation with respect to risk management,
control and review processes that it had in place for 2012/13.
The range of individual opinions arising from risk based audit assignments
The Trust has produced a Quality Account, and has taken steps to assure itself of the
accuracy of this document by referencing Information Services within the organisation, the
Quality and Safety Committee and Internal and External audit processes.
Significant Issues
During the year the Trust identified the following significant control issues
During 2012/13 the CQC visited Lincoln County Hospital in both April and
October/November 2012. At the visit in April they reviewed outcome 9 ( management of
medicines ) and judged it to be non-compliant. At the visit in October / November 8 out of
the 9 outcomes reviewed were judged to be compliant. This included outcome 9. The
current position at the end of March 2013 is that Lincoln County Hospital is compliant with
15 regulations/outcomes. There is still a minor impact relating to the following
regulations/outcomes.
•
Regulation 22/Outcome 13 Staffing
A Remedial action plan to address this impact on patients is being implemented.
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During 202/13 the CQC visited Pilgrim Hospital in both May and December 2012. At the
visit in May they reviewed outcome 9 ( management of medicines ) and judged it to be noncompliant.. At the visit in December 8 out of the 10 outcomes reviewed were judged to be
compliant. This included outcome 9. The position at the end of March 2013 is that Pilgrim
Hospital is compliant with 14 regulations/outcomes. There is still a minor impact relating to
the following regulations/outcomes.
•
•
Regulation 9/Outcome 4
Care and welfare of people who use services
Regulation 22/Outcome 13 Staffing
Remedial action plans to address these impacts are being implemented.
In August 2012, the CQC visited County Hospital, Louth as part of a national targeted dignity
and nutrition inspection programme. The CQC reviewed 5 outcomes and they were all
judged to be compliant. The position at the end of March 2013 is that County Hospital Louth
is compliant with all 16 regulations/outcomes.
In February 2013 the CQC visited Grantham Hospital and 3 out of the 6 outcomes reviewed
were judged to be compliant. The position at the end of March 2013 is that Grantham
Hospital is compliant with 13 regulations/outcomes. There are minor impacts relating to the
following regulations/outcomes T
Regulation 22/Outcome 13 Staffing
Regulation 23/Outcome 14 Supporting workers
Remedial action plans to address these impacts are being implemented.
The Trust has not participated in any special reviews by the CQC during 2011/12.
With the exception of the issues that I have outlined in this statement, my review confirms
that United Lincolnshire Hospitals NHS Trust has a system of internal controls that supports
the achievement of its policies, aims and objectives and that those issues highlighted have
been or are being addressed.
Accountable Officer : Ms Jane Lewington, Chief Executive
Organisation: United Lincolnshire Hospitals NHS Trust
Signature
Date
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Appendix 2: Independent Auditor’s Limited Assurance Report To The
Directors Of United Lincolnshire Hospitals Nhs Trust On The Annual Quality
Account
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