Western Sussex Hospitals NHS Trust
Quality Account
2012 / 2013
Contents
Part 1:Statement by our Chief Executive
Part 2:Priorities for improvement in 2013/14
Priority 1: Infection control
Priority 2: Reducing avoidable mortality
Priority 3: Measuring safety culture in clinical services
Priority 4: Care, compassion and communication
Priority 5: Improving clinical records and clinical coding
Statutory statements regarding Clinical Quality
Relevant Health Services and Income
Participation in National Clinical Audits and National Confidential Enquiries
Research as a driver for improving the quality of care and patient experience
Incentives for Improved Quality
External Regulation
Data Quality
Core Quality Indicators
Part 3:How have we done?
Improving maternity care
Other quality areas where we have been striving for improvement
- Quality achievements relating to CQUIN, Strategic Health Authority and Local Priorities
- Quality achievements relating to the NHS Performance Framework
- The Enhancing Quality and Recovery Programme
Who was involved in the content of this report and the priority setting?
Statement of Directors’ responsibilities
Appendix 1: National Clinical Audits (listed by the National Clinical Audit Advisory Group)
Appendix 2: Actions resulting from reviews of national clinical audits
Appendix 3: Actions resulting from reviews of local clinical audits
Annex 1: Statements from stakeholders regarding this Quality Account
Annex 2: Report provided by external auditors
1
Part 1 - Statement by our Chief Executive
We have prepared our Quality Account this year in the wake of the publication in February of the
final report of the independent inquiry into care provided by Mid Staffordshire NHS Foundation Trust.
Whilst we are confident that our own standards of care are high, we are, like all NHS hospitals,
reviewing many aspects of our systems in the light of the report’s recommendations. Robert Francis
QC concluded his report by saying “People must always come before numbers. Individual patients
and their treatment are what really matters. Statistics, benchmarks and action plans are tools not
ends in themselves. They should not come before patients and their experiences. This is what must
be remembered by all those who design and implement policy for the NHS.”
I give my commitment that all members of staff in our Trust will be expected to remember this
important principle – to care about every single patient as an individual.
During the past year, we won national recognition for the way that patient safety has been prioritised,
‘from the board to the ward’. The Trust took the top prize in the ‘Board Leadership’ category of the
Patient Safety Awards 2012 organised by the Health Service Journal and Nursing Times. We are
proud to have earned an enviable reputation for patient safety since the Trust was created in April
2009. The awards panel commended the Trust for its effective reporting systems at ward level, the
way that Board members are informed and involved, and the way that information is matched against
patient feedback.
Keeping our patients safe is the most fundamental responsibility of everyone in our Trust. We will
continue to set patient safety and quality at the heart of all that we do. For us, this means never being
content with the quality of our services but constantly trying to make them safer and better. Systems
for measuring and improving our quality are essential to driving further improvements, but we also
know that the very highest standards will only be achieved if we maintain an excellent safety culture
throughout all parts of our hospitals.
Our Quality Strategy was developed in discussion with our clinicians and other stakeholders. It
set priorities for quality improvement that address key issues of patient safety, patient outcomes
and patient experience. Within the Trust, our Quality Board meets regularly to oversee progress in
meeting the goals we set ourselves in our Quality Strategy and the Trust Board receives a quality
report every month. Our Quality Strategy will be updated during 2013-14 to take account of our most
recent reviews of services, detailed information about quality, and advice from the Trust Board and
our Council of Governors.
We describe in the following pages the progress we have made in the five priorities for improvement
that we set ourselves last year: infection control; reducing avoidable mortality (in pneumonia, chronic
obstructive airways disease, acute renal failure, and chronic heart failure); improving maternity
care; care and compassion; and improving clinical records and clinical coding. We have made real
improvements in each of these areas. We also provide details of other quality improvements.
In our quality improvement priorities for next year, we will introduce new arrangements for measuring
safety culture in a number of key clinical services. This will help us identify any potential areas for
improvement and to measure these improvements following any interventions that are found to be
necessary.
Although maternity care has not been identified explicitly as one of our key priorities for improvement
in 2013-14, we will continue to monitor carefully the quality of our care in this important area in order
to maintain the high standards being achieved. Results of this monitoring will be reported monthly to
the Trust Board and Board of Governors.
Arrangements for assuring ourselves of the care and compassion that patients experience from
2
their contact with our staff continue to be strengthened. We recognise that, whilst safe and effective
treatment is fundamental to the services we provide, care and compassion are also essential
ingredients of the experiences to which our patients and their carers are entitled. From April, a
‘friends and family test’ will be added to the questions we ask patients about their experience. We
will ask patients whether they’d want a friend or relative to be treated in our hospitals in their hour
of need. We are determined to always be caring and compassionate across all our services and
departments and we are therefore again including this as a priority for 2013/14.
We also need to remain vigilant about our performance on infection control, and reducing avoidable
mortality in the key areas identified last year, and these also remain as priorities for further
improvement in 2013/14. Finally, we need to maintain the progress we have made in improving our
clinical records and clinical coding, and this will again be a priority for improvement in 2013/14.
We believe the priorities we have set for quality improvements this year are meaningful to patients,
clinicians and the community we serve. Our goals for quality improvement are challenging but
achievable.
Our Quality Strategy and work involve all our staff and stakeholders. We will continue to consult with
them as we tackle our quality improvement priorities in 2013/14 and as we plan further ahead. We
have strong governance arrangements to provide assurance about the progress we are making in
quality and safety. Once we are a Foundation Trust, we will also be formally accountable for quality to
our members through a Council of Governors.
The information contained within this quality report is, to the best of my knowledge, accurate.
Marianne Griffiths
Chief Executive
3
Part 2 - Priorities for improvement in 2013/14
We continue to set ourselves an ambitious programme of improvements and to place patient safety
and quality as our prime focus. As we said in our previous Quality Accounts, we do not want these to
be hollow words, and that means placing a relentless focus on quality. We are determined to deliver
services to our patients that are safe and effective and put our patients, and their experience of our
care, at the heart of what we do.
This year, we have made further substantial progress in addressing the challenges we set ourselves
in a Quality Strategy. This underpins our clinical strategy and provides a framework to drive up further
the quality of our services in a number of ways. Our Quality Strategy objectives are shown in the
table below. During 2013, we will be undertaking a review of our Quality Strategy and updating it to
take account of recent changes to services, detailed information about quality and performance, and
advice from the Trust Board and our Council of Governors.
Quality Strategy Objectives
Domain 1: Improving Clinical Outcomes by reducing overall mortality
1.1
Improve mortality in specific conditions amenable to treatment
1.2
Reduce mortality following hip fracture
1.3
Reduce the rate of readmission following discharge from the Trust
1.4
Improve maternity care by encouraging natural childbirth
1.5
Ensure active engagement with research
1.6
Improve data quality
Domain 2: Patient Safety
2.1
Improve safety of prescribing
2.2
Reduce incidence of healthcare associated venous thromboembolism
2.3
Reduce incidence of hospital acquired infection
2.4
Improve theatre safety for patients
2.5
Reduce the number of falls in hospital
2.6
Reduce pressure damage in hospital
Domain 3: Patient Experience
3.1
Use feedback from real time patient experience project to improve care
3.2
Reduce the number of patients suffering a poor experience when dealing
with the Trust
3.3
Improve the nutrition of hospital in-patients through the use of nutritional assessment,
action planning and evidence of assistance with feeding when required
3.4
Improve cleanliness and our PEAT scores
3.5
Improve customer service and become known as a more caring organisation
Our Quality Board has continued to pull together all of the different pieces of work relating to
improving quality under one umbrella. The Quality Board ensures that the lessons we learn about
improving quality in one area are spread across the whole Trust – between hospitals and between
clinical areas. The Quality Board and the Trust Board continue to receive a regular, monthly quality
report which describes the Trust’s performance against key national, regional and local quality
indicators, including those set out by our Quality Strategy. Quality performance is also monitored by
4
our Quality & Risk Committee as part of our Trust quality governance arrangements, and once we
become a Foundation Trust, we will also be formally accountable for quality to our members through
a Council of Governors.
Following consultation with staff and patients, we have identified five specific areas for improvement
in 2013/14 that we set out below as a part of this year’s Quality Account. These are Infection Control;
Reducing Avoidable Mortality; Measuring Safety Culture in Clinical Services; Care, Compassion and
Communication; and Improving Clinical Records and Coding.
5
Priority 1 - Infection Control
Why is this important?
Serious infections acquired by patients while they are in hospital became an increasing problem in
the last 20 years or so. Increased use of antibiotics around the world has led to the development of
bacteria that are resistant to antibiotics, the most well known of these is MRSA (Methicillin-resistant
Staphylococcus aureus). This organism is found not only in hospitals, but also in the community as a
whole. In most people it causes no harm, but if their normal defences are weakened by other illness
or injuries then the bacterium can get into their bodies and cause blood stream infections that are
very serious.
Simply relying on new antibiotics to cure infections like MRSA is not enough, partly because soon the
bacteria become resistant to the new antibiotics too. There is no simple answer to reducing MRSA
infection rates and it requires multiple different interventions. We screen all patients entering hospital
for MRSA on their skin and in their nose (the commonest places to find it) and for those who have
it we prescribe treatment. Good cleaning and good hand hygiene by staff, patients and visitors also
help to reduce rates of infection.
Another problem that has developed with the widespread increased use of antibiotics is C.difficile
associated diarrhoea. C.difficile is a bacterium that lives in the gut of many healthy people alongside
many other bacteria, and causes no problems at all. When antibiotics are given repeatedly or for
prolonged periods, however, then the other bacteria may be killed leaving the C.difficile to multiply.
C.difficile produces a toxin that can cause severe diarrhoea and this diarrhoea may also carry spores,
which can spread the infection to others. Most cases of C.difficile diarrhoea, however, are due to the
patient’s antibiotics affecting their own bacteria rather than spread from one patient to another.
There are two main actions we use to prevent C.difficile. First, we have strict antibiotic prescribing
policies to reduce the chances of it developing. Second, and in order to prevent spread from one
patient to another, we isolate patients who develop diarrhoea, and adopt particularly scrupulous
hygiene measures when treating these patients. All areas that have had patients with C.difficile are
deep cleaned after the patient recovers. From 2011/12, the Chief Executive has chaired the Root
Cause Analysis of all hospital acquired C.difficile and MRSA bacteraemia cases.
How do we monitor it?
We measure the total number of patients who have
MRSA bacteraemia discovered on blood sampling.
From 2010 onwards only those cases that develop
the infection after 48 hours of admission are
recorded as hospital acquired.
We also measure the number of patients in whom
C.difficile toxin is found in stool samples. Those
patients who are positive 72 hours after admission
are recorded as hospital acquired cases.
There was one case of hospital acquired MRSA on WSHT sites in 2012/13
6
How do we report on it?
The numbers are reported each month to
our public Board meeting. In addition a full
investigation is made into all MRSA bacteraemia
and C.difficile cases and the results of the
investigation are reviewed at a meeting with the
Chief Executive, Director of Nursing and Medical
Director. This ensures that swift corrective action
can take place, and the learning from each event is
shared Trust-wide.
The number of cases of hospital acquired C.difficile continues to fall
What progress did we make in 2012/13?
We had one patient with MRSA bacteraemia in 2012/13, below the limit of two cases that we had
been set by the Department of Health. We carried out a careful assessment of this case which
showed that the case was unavoidable and that all aspects of safe infection control standards were
followed. We had 72 cases of C.difficile, below the limit set for us by the Department of Health of 75
cases.
What is our goal for 2013/14?
In 2013/14, we will maintain our continuous programme of measures to control and reduce hospital
acquired infection, and investigate any cases using Root Cause Analysis. We have a ‘zero tolerance’
approach when applying and monitoring our infection control policy.
The limits we have been set this year for hospital acquired infection are zero avoidable cases for
MRSA bacteraemia and 46 cases for C.difficile.
7
Priority 2 - Reducing Avoidable Mortality
Why is this important?
About half of all deaths in the UK take place in hospital. The overwhelming majority of these deaths
are unavoidable. The person dying has received the best possible treatment to try to save his or
her life, or it has been agreed that further attempts at cure would be futile and the person receives
palliative treatment.
We know, however, that in all healthcare systems things can and do go wrong. Healthcare is very
complex and sometimes things that could be done for a patient are omitted or else errors are made
which cause patients harm. Sometimes that means that patients die who might not have done had
we done things differently. This is what we mean by “avoidable mortality”. Obviously by concentrating
on this we will end up with safer hospitals and save lives.
How do we monitor it?
The usual way of comparing hospitals’ mortality is to calculate standardised mortality rates. These are
measures that try to make adjustments for how sick the patients going to a particular hospital are, the
kind of treatments offered, the age of the patients and what their living conditions are like at home.
This should allow comparison between hospitals seeing greater or lesser proportions of very sick or
very elderly patients, or patients from more or less deprived areas within the national picture as a
whole. After the adjustments to take account of all of the above, the results are reported as a ratio
so that an average hospital would have a rate of 100. A rate greater than 100 suggests a higher than
average standardised mortality rate and less than 100 a better than average rate.
There are different ways of calculating these standardised mortality rates, which can be very
confusing. One measure, called the Hospital Standardised Mortality Ratio (HSMR), is published by
an organisation called Dr Foster and has been widely used for some years. In 2011, the Department
of Health introduced another measure called the Summary Hospital-level Mortality Indicator (SHMI).
As indicated in our previous Quality Account, for 2012/13 we have been monitoring our performance
using both the HSMR and SHMI.
Although standardised ratios are useful for comparing hospitals, for trying to reduce the overall death
rate in a hospital we use simple month-by-month mortality rates. It is these that are monitored by the
group that is leading our drive to reduce mortality rates.
We also receive information from a number of different organisations that monitor different areas of
treatment. For example, the year before last, we had received information on two occasions that we
had a higher than expected death rate for patients who had been admitted with broken hips (fractured
neck of femur and head of femur repair). As a result we reviewed the care in that area and made
rapid improvements so that the death rate has improved greatly. In a recent independent review of
hip fracture services at Western Sussex Hospitals this pathway was described as an ‘exemplar of
good practice’.
How do we report on it?
The Dr Foster HSMR, SHMI, and crude mortality figures are reported to the Trust Board every month
as part of the regular quality report. Senior clinical leaders also review the crude mortality numbers
monthly.
8
What progress did we make in 2012/13?
We set ourselves a goal in 2012/13 to maintain our Dr Foster HSMR at a level below 100, i.e. better
than similar NHS Trusts, and to reduce it further from our 2011/12 figure. There is a two month delay
with Dr Foster data (to allow for coding and processing of data) but our HSMR for the twelve months
to January, the latest figure available, was 96.7, compared to 108.5 for the same period last year. (All
figures are based on applying the most recent 2011/12 benchmark to ensure like for like comparison).
The Summary Hospital-level Mortality Indicator (SHMI) was introduced in 2011. For the twelve
months to September 2011, our SHMI was 1.10 (where 1.00 is the average for similar Trusts),
a score classified as ‘as expected’ by the Health & Social Care Information Centre. We also set
ourselves the goal of reducing our SHMI score further in 2012/13. Because of the way this measure
is calculated (with our performance being re-benchmarked to all Trusts nationally on a quarterly
basis), progress in reducing this number has been slower than with the HSMR. Quarter by quarter,
however, there has been a gradual reduction in the Trust score. The most recent data relating to the
SHMI was published by the Health & Social Care Information Centre on April 24th (relating to October
2011 to September 2012) and gave the Trust a SHMI value of 1.06, a reduction on the figure for the
12 months to September 2011. The official banding of this indicator published on the Health & Social
Care Information Centre website and NHS Choices shows the Trust band remains ‘as expected’.
Each year, the Dr Foster organisation rebases
its methodology to take account of improving
mortality rates nationally. Based on the most
recent (2012) rebasing our HSMR has improved
from an HSMR of 108.5 (for February 2011 to
January 2012) to 96.7 for the most recent 12
months of data available (February 2012 to
January 2013), again meeting our goal for this
indicator.
=100
For 10 of the last 12 months the HSMR has been below 100 and the 12
month rolling average has steadily fallen to 96.7
3.30
Crude mortality continues to fall year on year.
9
3.24
Crude mortality is measured in relation to
non-elective activity only. The Trust set a goal
of achieving a 10% reduction in mortality by
December against a 2010/11 baseline. This worked
out as a reduction of 8.7% for the year overall
(the trajectory ran from April 2011 to December
2012 and therefore only had a part-year effect for
2012/13).
The Trust made good progress in the first part of the year and succeeded in reaching the 10%
reduction in December. The Trust has been very close to the required level in January and February,
but the unseasonably cold weather in March has meant that we have not seen the usual decrease in
mortality in the final month of the year.
Overall crude non-elective mortality in 2012/13 was 3.24% compared to 3.30% in 2011/12 and 3.60%
in 2010/11.
In addition to reducing both crude and risk adjusted mortality we also aimed for 10% reductions in
crude mortality in a number of specific conditions, namely:
•
•
•
•
Pneumonia
Chronic Obstructive Airways Disease (COPD)
Acute Renal Failure
Chronic Heart Failure
During the past year, we introduced new ‘care bundle’ systems of care for patients with these
conditions. Care bundles are small sets of evidence-based interventions which, when used together
consistently by a single healthcare team, have been shown to significantly improve patient outcomes.
We also continued to deploy Patientrack, an advanced observation and assessment system that
gives our nurses and doctors early warning if a sick patient’s condition is deteriorating, and thereby
helps early and effective intervention to get things back on course. Patientrack increases patient
safety and we expect it to help in reducing
avoidable mortality.
Our target was to achieve a 10% reduction in each
of these specific clinical conditions by March 2013
based on 2011/12 levels (as such we would not
see a full 10% reduction for the year as a whole).
We have seen reductions in three of the four
clinical conditions. For COPD and Chronic Heart
Failure this reduction is in line with a trajectory to
Crude mortality reduced for three of the four key conditions.
reach the 10% target. We have made progress
with reducing mortality in patients with pneumonia,
although not yet to our target level. Mortality in patients admitted with acute renal failure was actually
slightly higher in 2012/13 compared to 2011/12 and we are investigating this carefully to understand
the reason for the increase and to improve in 2013/14.
What is our goal for 2013/14?
In 2013/14, we wish to maintain our Dr Foster HSMR at a level below 100, i.e. better than similar
NHS Trusts, and reduce it further from our 2012/13 figure. We also aim to reduce our SHMI score
further in 2013/14.
We will continue to seek further reductions in crude mortality. We intend to maintain our focus for
a further year on reducing crude mortality in the specific conditions that we identified last year,
to ensure that the changes we made this year are truly embedded and that the improvements in
mortality that are emerging are maintained. We will focus especially carefully on mortality in patients
admitted with acute renal failure.
10
Priority 3 - Measuring Safety Culture in Clinical Services
Why is this important?
Many millions of treatments are given to patients every year, with overall good results to their health.
But healthcare is complex and also involves risks. For example, in discussion with their patients,
doctors often have to balance the expected benefits of a treatment with its potential to do some harm,
such as a drug that may have unwanted side effects. Some risks are inherent in treatment whilst
others can be eliminated or substantially reduced by activities aimed specifically at improving patient
safety.
We already have strong systems and safeguards to enhance the safety of our patients. For example,
during 2012/13, we were awarded Level 2 compliance with general standards for safety set by
the NHS Litigation Authority (NHSLA) and with a special set of standards called CNST (Clinical
Negligence Scheme for Trusts) for maternity care. This level of award demonstrates that our patient
safety policies and principles have been effectively embedded into practice and that we have
appropriate processes for managing and minimising risk.
We know, however, that the very highest standards can only be attained if safety is embedded in the
culture of our organisation – in the values, attitudes and behaviours of all our staff.
Quality monitoring in the NHS is designed to measure a number of important safety factors and
provides a trigger to investigate anything that might be going wrong. In many industries that involve
risk, such as the airline industry, interest has more recently focused on measures that are likely
to predict and promote safety, including measuring ‘safety culture’. Measuring safety culture in
healthcare can provide valuable information about what we need to do to improve patient safety
further, and repeat measurements can be used to evaluate the success of any such interventions.
Indeed, the very activity of measuring safety culture has been shown to raise awareness and
enhance safe behaviours.
How do we monitor it?
Measuring safety culture in healthcare is in its infancy. A number of survey tools have, however, been
developed and shown scientifically to work well at measuring the perceptions of staff to a number
of key safety culture factors. For example, the Safety Attitudes Questionnaire (SAQ) measures staff
attitudes to: teamwork climate; safety climate; perceptions of management; job satisfaction; working
conditions; and stress recognition.
Where are we starting?
Although we have always promoted a culture that values the importance of patient safety, we have
never tried explicitly to measure safety culture. In recent years, information has been emerging about
how to do this and some reports have been published that can now guide our use of the SAQ or a
similar survey tool in several important clinical areas.
What is our goal?
Before September 2013, we will use a validated survey tool, probably the SAQ, to make baseline
measurements of the safety attitudes of our staff in the following services:
11
Operating theatres
Pharmacy
-
Elderly care
We will undertake analyses of the survey results to identify any areas where safety improvement
interventions could be applied and then repeat the surveys within six months of the interventions
being completed.
Based on our learning from this initial group of safety culture studies, we expect to extend the
approach to further areas.
12
Priority 4 - Care, Compassion and Communication
Why is this important?
In our Trust Vision, we have told patients “we care about you”. This core value is reflected in a
strategic objective to ensure that all patients are treated with care and compassion, by all staff, and at
all times. We have promised patients that:
We will embed a culture of customer focus throughout the Trust to ensure that we treat patients with
kindness, dignity and respect. This will be evidenced through improvements in our patient survey and
in real-time feedback from patients and carers.
The publication of the Francis Report into care provided by Mid Staffordshire NHS Foundation Trust
is a reminder that all members of our staff must care about every single patient as an individual.
How do we monitor it?
The National Inpatient Survey conducted on behalf of the Care Quality Commission (CQC) provides
a detailed picture of how patients view us on a number of dimensions, and includes measures that
relate strongly to the care and compassion shown by individual staff and by the organisation as a
whole. We will continue to participate in the National Inpatient Survey and will maintain careful and
thorough scrutiny of all patient complaints and enquiries made through our Patient Advice and Liaison
Service (PALS).
The National Inpatient Survey is a snap-shot at one point in time and we supplement this with
much more frequent surveys conducted internally. During 2011-12, we introduced ‘real time’ patient
experience data collection, enabling rapid assessment of what patients are telling us, and prompt
intervention to put right any deficiencies. Data collection has been designed to address a broad range
1
of patient experience measures, including all CQUIN questions , and other questions about care
and compassion. Over the past year, we have used findings from the 2011 National Inpatient Survey
and previous internal patient surveys, as well as themes that emerged from analyses of patient
complaints and enquiries to PALS, to target our real time patient experience activity. We now survey
around 20% of all adult inpatients to learn about their experiences.
How do we report on it?
The results of the National Inpatient Survey are reviewed by the Trust’s Quality Board and reported to
the Trust Board. Findings from internal patient surveys are also reviewed by the Quality Board, and
discussed with our Stakeholder Forum Group.
The Real Time Patient Experience programme is now used across the Trust for inpatients,
outpatients, maternity, cancer and children’s services. Results are reported to the Trust Board in a
monthly quality report and our clinical divisions use the data to identify areas of concern, take forward
improvement measures, and monitor improvements. Progress is also reported through our divisional
quarterly governance reviews.
1 - These questions are part of the nationally mandated CQUIN focussing on responsiveness to patient needs, including
whether patients feel they are offered enough privacy, involved in the decisions relating to their treatment and given the
opportunity to raise questions about fears or worries relating to their care.
13
What progress did we make in 2012/13?
The findings from the 2012 National Inpatient Survey for Western Sussex Hospitals NHS Trust have
been published by the Care Quality Commission (CQC). The survey asked the views of adults who
had stayed overnight as an inpatient in August 2012. Our inpatients were asked what they thought
about different aspects of the care and treatment they received during their stay in our hospitals.
We are pleased that the survey continues to show that most of our patients feel that they have been
2
treated with dignity and respect . The score for this part of the survey places us about the same as
the majority of Trusts nationally and about the same as our score last year. We had aimed to increase
our score from the previous year and become ranked amongst the best Trusts; this will remain a
goal for 2013/14. We also set ourselves a goal to increase the number of people in the survey who
reported that they had been asked about the quality of service they had received as a patient. We
are pleased that this year’s survey demonstrated a significant increase from last year in the number
of patients who reported that their views about quality had been sought. It also demonstrated that our
nurses are taking care to ensure that patients get answers to their questions, and that patients have
confidence and trust in their nurses, with significant increases from last year in the survey’s scores for
these questions. Our nurses understand the importance of including their patients in conversations
and the survey showed that we are in the highest performing Trusts when our patients were asked
‘did nurses talk in front of you as if you weren’t there?’
In a number of other important practical ways, such as reducing the number of occasions when
patients share sleeping areas with patients of the opposite sex, sharing of shower or bath facilities
with patients of the opposite sex, and being given enough privacy when being examined or treated
in the A&E department, the survey also shows that we have maintained our strong position from the
previous year.
Although these results are encouraging, we need to strive continually for improvements so that every
individual patient who comes through our doors feels that they have been treated with kindness and
respect, by all staff and at all times.
Our Real Time Patient Experience (RTPE) system enables us to undertake much more frequent
surveys of how patients feel about their experiences. From January 2012 to March 2013, 8,500
surveys have been completed by patients in many different areas, including inpatient wards, Accident
& Emergency Departments, Outpatient Departments, children’s services and maternity. For 2012/13,
on average around 370 patients were surveyed every month on our wards. The number of surveys
being conducted continues to increase, and we have recently added new surveys of patients
receiving care for cancer, a survey for young adults to complete, and a survey about experiences of
end of life care. The results from surveys are being used at all levels of the organisation to monitor
performance and identify areas for improvement.
We set ourselves specific targets last year about how patients would report their experience of our
staff. Using our real time surveys, we asked about whether we had shown respect for their privacy,
and therefore protected their dignity, and whether staff had shown kindness when caring for them.
We are very pleased that we met our 97% target for patients reporting that staff providing their care
were kind to them.
2 - Our ratings from the National Inpatient Survey were based on the responses of nearly 500 patients who had at least
one overnight stay at St Richard’s or Worthing Hospitals in August 2012
14
The Trust participates very actively in a peer review Care & Compassion programme (also called ‘Sit
and See’) and had an external review in October 2012 from a Trust in Surrey. The review sought to
identify ‘positive, passive or poor interactions’ between staff and patients and visitors in relation to
general patient care and ‘patient and visitor engagement’. It rated 87% of observed general patient
care interactions as positive and 72% of interactions in the patient and visitor engagement category
as positive. Although these results are encouraging, we will be aiming for improvements of at least
5% in each of these scores at our next external review in October 2013.
We have also participated in other peer review and development activities that are designed to share
best practice and help us identify opportunities for improvement in the ways we deliver care. One
of these focused on our services for people with learning disabilities and the other on privacy and
dignity. Feedback from the privacy and dignity peer review described our staff as inspirational and
motivated with a passion for caring.
What is our goal?
All improvement initiatives previously supported by stakeholder ‘task and finish’ groups have
demonstrated positive improvements and, as in previous years, our plan for improvement in 2013/14
is being developed in partnership with our stakeholder forum. The principal themes for 2013/14 will
be: nutritional support; information on discharge; and communication throughout the patient pathway.
We will aim for an improvement in 2013/14 to the number of patients who report through our RTPE
programme that we have protected their privacy, setting ourselves a target of at least 90% of patients
rating us as good or excellent.
The National Inpatient Survey indicates that too many of our patients last year didn’t receive enough
help to eat their meals. Working with our hospitals voluntary service, we have already introduced a
‘Dining Companions’ scheme and we expect to see a significant improvement in this aspect of our
patients’ experiences when reported in future surveys. Our goal is to increase our score to at least
7.0 in the next survey.
Although previous National Inpatient Surveys have shown encouraging improvements in our scores
for written or printed information given to patients on what they should or should not do after leaving
hospital, we recognise that we have more to do. The most recent National Inpatient Survey suggests
that we need to do more about giving patients clear information on what to expect and do after
leaving hospital, and that the letters between hospital doctors and family doctors should be written in
a way that is more easily understood by patients. We therefore aim to increase our scores by at least
10% in the next National Inpatient Survey for three questions:
i)
ii)
iii)
before you left hospital, were you given any written or printed information about what you
should or should not do after leaving hospital?
did hospital staff tell you who to contact if you were worried about your condition or treatment
after you left hospital?
If you received copies of letters sent between hospital doctors and your family doctor (GP),
were these written in a way that you could understand?
We will continue to participate in all these activities aimed at measuring and improving our patients’
experiences of our services. This year, we also plan to take forward the vision and strategy for
nursing, midwifery and care staff called ‘Compassion in Practice’ and thereby promote even stronger
values of care, compassion, competence, communication, courage and commitment amongst all our
staff.
15
Priority 5 - Improving Clinical Records and Clinical Coding
Why is this important?
Maintaining good clinical records is important for the safety of our patients. Patients are often
transferred between teams and wards whilst in hospital and it is essential that notes about their
condition and treatments are carefully recorded so that clinical staff know what has already occurred.
It is also important that clinicians have a good record of any previous episodes of hospital care.
Every time a patient is admitted to hospital, the diagnoses that are made of their condition and any
procedures they receive are described in the clinical record and then coded. This coding enables
important analyses to be undertaken that help us understand trends in our activity and performance.
Coded and anonymised data is also used by external organisations, such as Dr Foster and the Care
Quality Commission, to monitor how well we are doing in treating different groups of patients, and by
our commissioners.
How do we monitor it?
We undertake regular audits of clinical records to assess how well they are being maintained. The
accuracy of our clinical coding is assessed internally through audit studies and externally by the Audit
Commission as part of a Payment by Results audit.
What progress did we make in 2012/13?
In 2012/13, our goals were to set and implement new standards for maintaining accurate and
comprehensive clinical records, and to take actions to improve clinical coding.
As planned, we established and implemented a new style of clinical records, using a format
recommended as best practice by the Royal College of Physicians; and we have introduced a
programme of spot checks to ensure that this improved documentation is being used consistently
throughout our hospitals.
One of the key indicators we use to determine the quality of clinical records is whether or not it is
clear who has made important entries. We set ourselves a challenging improvement target of 70%
or more of all important entries showing the identity of the author. We have re-audited samples of
clinical records in 2012/13 to assess how well they are being maintained. The audit showed that
94% of entries were signed, though only 62% recorded a legible printed name. Although it would
usually be possible to identify the author of an entry from a signature alone, we need to do more to
encourage the better practice of recording a printed name alongside the signature.
In our last Quality Account, we also undertook to re-audit clinical coding and seek improvements in
accuracy to the level of no more than 6% of primary and secondary diagnosis and procedure codes
being incorrect. Our 2012/13 audit demonstrated reductions to less than 6% for three of these coding
categories; coding errors for secondary procedures remained slightly higher at 7.7% though this rate
was lower than the previous year.
What is our goal for 2013/14?
We will undertake re-audits of samples of clinical records in 2013/14 and are setting ourselves a goal
of 95% or more of all important entries showing a legible printed name as well as signature to confirm
the identity of the author. Later in this report, we describe the actions we plan to take to improve the
quality of data and clinical coding of information in clinical records.
16
Statutory statements regarding Clinical Quality
Relevant Health Services and Income
During 2012/13 Western Sussex Hospitals NHS Trust provided and/or sub-contracted 102 relevant
health services. The Western Sussex Hospitals NHS Trust has reviewed all the data available to
them on the quality of care in all 102 of these relevant health services.
The income generated by the relevant health services reviewed in 2012/13 represents 100% of
the total income generated from the provision of relevant health services by the Western Sussex
Hospitals NHS Trust for 2012/13.
Participation in National Clinical Audits and National Confidential
Enquiries
Clinical audit is the process by which clinical staff measures how well we perform certain tests and
treatments against agreed standards and then develop plans for improvement. It is a key part of
continuous quality improvement. Western Sussex Hospitals NHS Trust, like other NHS organisations,
participates in national audits - where care across the country is assessed (and sometimes
organisations are compared with each other) - as well as locally organised audits. The National
Confidential Enquiries are similar but use in depth reviews of what occurred in order to develop new
recommendations for better care of patients.
During 2012/13, 37 national clinical audits and six national confidential enquiries covered relevant
health services that Western Sussex Hospitals NHS Trust provides.
The above national clinical audits and confidential enquiries are those listed by the National Clinical
Audit Advisory Group and made available at the Department of Health website. They are shown in
appendix 1.
During that period Western Sussex Hospitals NHS Trust participated in 95% national clinical audits
and 100% national confidential enquiries of the national clinical audits and national confidential
enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Western Sussex Hospitals NHS
Trust was eligible to participate in during 2012/13 are shown in Appendix 1. The national clinical
audits and national confidential enquiries that Western Sussex Hospitals NHS Trust participated in
during 2012/13 are shown in Appendix 1.
The national clinical audits and national confidential enquiries that Western Sussex Hospitals NHS
Trust participated in, and for which data collection was completed during 2012/13, are listed below in
Appendix 1 alongside the number of cases submitted to each audit or enquiry as a percentage of the
number of registered cases required by the terms of that audit or enquiry.
3
The reports of 26 national clinical audits were reviewed by the provider in 2012/13 and Western
Sussex Hospitals NHS Trust intends to take the following actions to improve the quality of healthcare
provided:
3 - Seven national reports are awaiting publication and two further audits are still in progress at the time of writing.
17
Reports of National Clinical Audits are disseminated to the Trust’s Clinical Divisions for their
actions. Main points of action for national clinical audits listed by the National Clinical Audit
Advisory Group are shown in appendix 2.
The reports of 82 local clinical audits were reviewed by the provider in 2012/13 and Western Sussex
Hospitals NHS Trust intends to take the following actions to improve the quality of healthcare
provided:
Reports of local clinical audits are disseminated to the Trust’s Clinical Divisions for their actions. Main points of action for a sample of local clinical audits are shown in appendix 3.
Research as a driver for improving the quality of care and patient
experience
The number of patients receiving relevant health services provided or sub contracted by Western
Sussex Hospitals NHS Trust in 2012/13 that were recruited during that period to participate in
research approved by a research ethics committee was 1,028.
Participation in clinical research demonstrates the commitment of Western Sussex Hospitals
NHS Trust to improving the quality of care it offers and to making its contribution to wider health
improvement. A ‘balanced’ portfolio of research studies supports excellent clinical care in a research
rich environment. Our strategic aim is to facilitate patients being offered new choices to participate in
the development of novel treatments, with the support of their clinicians. Through their participation,
patients gain earlier access to new treatments and the potential benefits that these bring.
The Trust continues to be a very active contributor to the national research effort as a member of
National Institute for Health Research (NIHR) research networks, including the Surrey & Sussex
Comprehensive Local Research Network (SSCLRN), two cancer research networks and several
other topic-specific research networks. During the last year, our links with the topic-specific networks
have strengthened. 86% of our clinical trials are part of the NIHR portfolio. We continued to work
closely with the SSCLRN Industry & Portfolio Managers and with our existing industry contacts to
identify research studies that would benefit our patients. This year, 15% of our research portfolio has
been supported by industry.
Our research nurse teams and support staff, working with clinicians in their specialist areas,
continued to offer research expertise in the set-up, screening and recruitment phase of studies. In
2013, we will publish our third report about our achievements in research and innovation, covering
the previous 12 months of the life of the Trust. This report will list all clinical research studies in which
the Trust was participating and provide details of the scientific articles published by its staff.
In 2012/2013 Western Sussex Hospitals NHS Trust was involved in conducting 173 clinical research
studies in a broad range of specialties. Of these, 104 studies were open to recruitment of patients; 69
were closed to recruitment but were continuing to follow up patients previously recruited. In particular,
the Trust supported a large number of studies in cancer, cardiology, critical care and bariatric surgery.
We also achieved our aim of increasing the numbers of research studies in paediatrics, obstetrics
and hepatology, as well as opening studies for patients under the care of rheumatology, diabetes
and dermatology services. During 2012/13, 79 clinical staff were Principal Investigators for clinical
research studies.
18
Incentives for Improved Quality
A proportion of Western Sussex Hospitals Trust income in 2012/13 was conditional on achieving
quality improvement and innovation goals agreed between Western Sussex Hospitals Trust and
any person or body they entered into a contract, agreement or arrangement with for the provision of
relevant health services, through the Commissioning for Quality and Innovation (CQUIN) payment
framework. Further details of the agreed goals for 2012/13 and for the following 12 month period are
available electronically at: http://www.westernsussexhospitals.nhs.uk/about-us/performance.
External Regulation
Western Sussex Hospitals NHS Trust is required to register with the Care Quality Commission and
its current registration status is “registered without conditions”. The Care Quality Commission has not
taken enforcement action against Western Sussex Hospitals NHS Trust during 2012/13.
Western Sussex Hospitals NHS Trust has not participated in any special reviews or investigations by
the Care Quality Commission during 2012/13.
Data quality
The data (numbers) with which we work need to be accurate in order for us to plan and deliver the
best possible care to our patients. These data are subject to a number of forms of independent
review.
Western Sussex Hospitals Trust submitted records during 2012/13 to the Secondary Uses Service
for inclusion in the Hospital Episode Statistics which are included in the latest published data. The
4
percentage of records in the published data:
which included the patient’s valid NHS number was:
99.6% for admitted patient care;
99.9% for out patient care; and
97.6% for accident and emergency care
which included the patient’s valid General Medical Practice Code was:
100.0% for admitted patient care;
100.0% for out patient care; and
100.0% for accident and emergency care.
Western Sussex Hospitals NHS Trust’s Information Governance Assessment Report overall score for
2012/13 was 73% and was graded green.
Western Sussex Hospitals NHS Trust was subject to the Payment by Results clinical coding audit
during the reporting period by the Audit Commission and the error rates reported in the latest
published audit for that period for diagnoses and treatment coding (clinical coding) were:
Primary Diagnoses Incorrect: 0%
Secondary Diagnoses Incorrect : 2.3%
Primary Procedures Incorrect: 5.6%
Secondary Procedures Incorrect: 7.7%
4 - Based on data for the first 10 months of 2012/13.
19
Western Sussex Hospitals NHS Trust will be taking the following actions to improve data quality:
1.
Undertake checks to ensure that improvements to patient case notes introduced in 2012/13
are maintained.
2.
Implement electronic discharge summaries across the Trust following successful piloting
during 2012/13
3.
Enhance training for clinical coders by involving trainers in case note audits and introducing an
annual assessment of coders.
4.
Continue to provide data quality workshops, targeting on services where problems are identified through audit and spot checks.
5.
Continue to involve senior clinical coders in audits of case notes arranged by the clinical
audit team.
6.
Embed the new exception reporting forms introduced during 2012/13 to ensure early identification of coding problems.
These actions will build on the progress made during 2012/13 to enhance data quality.
Core Quality Indicators
The following core quality indicators are relevant to Western Sussex Hospitals NHS Trust. They relate
to the NHS Outcomes Framework.
Summary Hospital-level Mortality Indicator (SHMI)
The Western Sussex Hospitals NHS Trust considers that this data is as described for the following
reasons: Mortality rates have been above the national average, but still within the expected range.
The mortality rate has steadily reduced and the Trust is particularly encouraged that the in-hospital
component of the SHMI is now 1.00.
The Western Sussex Hospitals NHS Trust intends to take the following actions to improve this
number, and so the quality of its services, by: (a) maintaining monthly reporting of mortality statistics
to Divisions and the Board; (b) focusing on the implementation of care pathways in key mortality
areas; and (c) reviewing arrangements for identifying and treating patients who deteriorate suddenly.
Summary Hospital-level Mortality
Indicator (SHMI)
Percentage of patient deaths with
palliative care coded at either
diagnosis or speciality level for the
trust for the reporting period
Oct 2010 to
Sept 2011
1.10
Oct 2011 to
Sept 2012
1.06 (as
expected)
National average (range)*
25.6%
13.5%
18.6% (0.3% to 46.3%)
1.00 (0.71 to 1.26)
*National average is based on July 2011 to June 2012.
20
Patient Reported Outcome Measures
The Western Sussex Hospitals NHS Trust considers that the outcome scores are as described for the
following reasons: These data, which are based on quality of life measures, show that our treatments
are effective in improving the health of our patients.
The Western Sussex Hospitals NHS Trust intends to take the following actions to improve these
outcome scores, and so the quality of its services, by: (a) ensuring regular feedback of PROMs data
to clinical teams; and (b) working with commissioners to ensure that treatments are offered to those
groups of patients most likely to benefit from the particular treatment.
Apr 2010 to
Mar 2011
(finalised)
Apr 2011 to
Mar 2012
(provisional
data)
Apr 2012 to
Sep 2012
(provisional
data)
National
average
(range)*
Groin hernia surgery: EQ 5D Index
(casemix adjusted health gain)
0.094
0.099
0.114
0.091 (0.017
to 0.158)
Hip replacement: EQ 5D Index
(casemix adjusted health gain)
0.385
0.387
0.425
0.437 (0.333
to 0.502)
Knee replacement: EQ 5D Index
(casemix adjusted health gain)
0.275
0.294
Not
available**
0.312 (0.244
to 0.387)
Not
applicable***
Not
applicable***
Not
applicable***
0.093 (0.077
to 0.128)
Varicose vein: EQ 5D Index
(casemix adjusted health gain)
* National average based on April 2012 to September 2012 (provisional data).
** Given the time lag for receipt of questionnaires pre and post-operatively, WSHT has not yet reached sufficient numbers for knee replacement for this to be reported by the HSCIC.
*** WSHT does not carry out sufficient numbers of varicose vein procedures to be included in this data.
28 day readmissions
The Western Sussex Hospitals NHS Trust considers that these percentages are as described for the
following reasons: While the Trust works hard to plan discharges appropriately, in some instances
readmissions still occur. The rate of readmissions is in line with peers.
The Western Sussex Hospitals NHS Trust intends to take the following actions to improve these
percentages, and so the quality of its services, by: continuing to work closely with commissioners
and other health organisations to identify patients at risk of readmission and putting in place services
to prevent them requiring further immediate hospital care. In particular we will identify those cases
where readmissions could have been prevented by organising care differently and make the
appropriate changes to reduce the level of readmissions.
21
2009/10
2010/11
National average
(range)
Patients 0 to 15 readmitted to a hospital which forms
part of the trust within 28 days of being discharged
10.99%
10.81%
9.99
(0% to 28.98%)
Patients 16 and over readmitted to a hospital which
forms part of the trust within 28 days of being
discharged
9.27%
10.43%
11.42%
(0% to 22.93%)
These figures are produced by the Health & Social Care Information Centre (HSCIC) and are indirectly standardised for
age, sex, method of admission, diagnosis and procedure. Data provided by HSCIC is for the age ranges given above:
data for patients aged 0-14 years and 15 years or over are not available.
Responsiveness to patient needs
The Western Sussex Hospitals NHS Trust considers that this data is as described for the following
reasons: the Trust’s involvement in Care and Compassion Reviews has ensured responsiveness to
the personal needs of patients in line with its peers.
The Western Sussex Hospitals NHS Trust intends to take the following actions to improve this data,
and so the quality of its services, by: (a) again making the care and compassion shown to patients a
priority for further improvement in 2013/14; (b) using results from real time patient experience tracking
to constantly identify areas for improvement; and (c) identifying areas for improvement from the care
and compassion peer review programme.
Responsiveness to the personal
needs of patients
2010/11
2011/12
2012/13
(estimate)
National average
(range)*
67.3
64.4
65.6
67.3
(56.5 to 85.0)
* National average based on 2011/12.
Proportion of staff who would recommend the Trust to Friends and Family
The Western Sussex Hospitals NHS Trust Considers that this percentage is as described for the
following reasons: Staff express concerns regarding how busy the hospital is and staffing levels.
The Western Sussex Hospitals NHS Trust intends to take / has taken the following actions to
improve this percentage, and so the quality of its services, by: introducing regular opportunities
for feedback from staff to enable us to capture their views about how we can improve. We are
also reviewing staffing ratios, particularly in ward areas and improving our staff engagement
(including communications) such that staff feel more able to contribute to, and be aware of, service
improvements.
Percentage of staff who would recommend the Trust
as a provider of care to their family or friends
*National average relates to 2011/12.
2011/12
2012/13
National average:
Acute Trusts (range)
66%
64%
65% (33% to 89%)*
22
Venous Thromboembolism (VTE) Risk Assessments
The Western Sussex Hospitals NHS Trust considers that this percentage is as described for the
following reasons: The Trust has focused on this area and made good early progress on embedding it
into normal practice. Further improvements are likely to require the use of new technology to capture
all patients.
The Western Sussex Hospitals NHS Trust intends to take the following actions to improve this
percentage, and so the quality of its services, by: (a) a continued focus in this area; (b) use of
Patientrack assessment module to streamline the process of data collection; and (c) an increased
emphasis on improving outcomes such as reducing rates of harm from VTE.
Percentage of patients admitted to hospital who were
risk assessed for venous thromboembolism
2011/12
2012/13
National
average
91.3%
93.4%
93.8%*
* National average based on April 2012 to December 2012.
C.difficile
The Western Sussex Hospitals NHS Trust Considers that this rate is as described for the following
reasons: While we have achieved major improvements, a relentless and constant focus is required to
continue to make progress. Particular challenges include the need for antibiotic usage in a frail and ill
patient population and balancing this with the risk of causing C.difficile disease.
The Western Sussex Hospitals NHS Trust has taken the following actions to improve this rate, and so
the quality of its services, by: (a) enhancements to our antibiotic prescribing policies; (b) heightened
environmental cleaning; and (c) targeted review of the patient pathway for these patients.
2010/11
2011/12
2012/13
National average
(range)*
Number of C.difficile (patients aged 2 or over)
125
76
72
NA
Rate of C.difficile per 100,000 bed days (patients
aged 2 or over)
38.3
23.3
22.7
21.8 (0 to 51.6)
*National average based on 2011/12
Patient Safety Incidents
The Western Sussex Hospitals NHS Trust considers that this number and/or rate is as described for
the following reasons: The Trust is the highest reporter of patient safety incidents in the South East
Coast Region for large acute Trusts. For no and low harm incidents the organisations reporting is
above the national average, with moderate, severe and fatal incidents recorded as less than the
national average. This signifies a positive reporting culture for learning and improving from when
things have gone wrong, with effective systems in place to minimise the risks of significant harm to
patients.
23
The Western Sussex Hospitals NHS Trust intends to take the following actions to improve this
number and/or rate, and so the quality of its services, by: The Trust will continue to (a) promote the
reporting of patient safety incidents across the organisation in order to learn and improve. Themes,
trends and learning from incidents will continue to be discussed and analysed through a variety
of forums including the Patient Safety Incident Review Group, Triangulation Group and Divisional
Governance Reviews. In addition, incidents will continue to be reviewed by a number of focus groups
(eg Falls, Safer Medicines, Health and Safety) to examine and learn from subject specific incidents
and establish actions to improve patient safety; and b) present a quarterly ‘CLIP’ (Complaints, Legal,
Incidents and Claims) report to the Trust Board. The report describes different sources of information
from ‘events’, each of which independently might not indicate an issue but which collectively may
identify a safety concern.
Apr 2011
to Sep
2011
April
2012
to Sep
2012
3996
6.53
National
average
(range)*
3935
6.53
Oct
2011
to Mar
2012
3478
5.77
Number of patient safety incidents resulting in severe
harm or death
8
2
3
NA
Percentage of severe harm or death incidents as a
percentage of the total incidents
0.2%
0.1%
0.1%
0.6%
Number of patient safety incidents
Rate of patient safety incidents per 100 admissions
NA
6.50
*Based on all ‘Large Acute’ organisations for April 2012 to September 2012. The most recent data for this indicator is the
data available from the Health and Social Care Information Centre (HSCIC) for April to September 2012. Information for
the remainder of the year is subject to further review and validation.
24
Part 3 - How have we done?
We have succeeded in the past year in driving up quality in a number of key areas. The progress
we have made in last year’s priority areas of infection control, reducing avoidable mortality, care and
compassion, and improving clinical records and clinical coding are described in part 2 of this Quality
Account. These remain important priorities for us this year.
One other priority last year, and in previous years, related to improvements in maternity care. We
describe the progress made for this priority below. Although maternity care has not been identified
explicitly as one of our key priorities for improvement in 2013/14, we will continue to monitor quality
in this important area carefully in order to maintain the high standards being achieved, and results of
this monitoring will be reported monthly to the Trust Board and Board of Governors.
During the year the Trust reported three Never Events and the Head of Internal Audit raised some
concerns regarding medicines management and the recording of consent to treatment. Details
of these issues as well as the action we are taking in response to them are set out in our Annual
Governance Statement which is available on our website or from the Company Secretary as part of
our Annual Report and Financial Statements for 2012/13.
Maternity care
Childbirth is a natural process, and medical interventions should be used only when they are required
to make birth safe when something has occurred to prevent natural birth. Medical interventions may
themselves carry risks, not only at the time they are undertaken but later on. For example, caesarean
section (removal of the baby through an operation on the mother’s abdomen) carries risks of bleeding
and infection and means the mother will probably be less active for the first few weeks of the baby’s
life. In addition, having one caesarean section means you are more likely also to need one if you
become pregnant again. Best practice is therefore to avoid caesarean section unless it is really
necessary but despite this we know that rates of caesarean section are high nationally, and rising.
Over 5,600 women had babies in our maternity department last year. The proportion of normal
deliveries (those not requiring any medical intervention) remained at around 64% of all births and
our caesarian section rate also remained similar to last year – with only a small fall from 24.8% to
24.7%. This is similar to the national average for caesarian rates. For the reasons described above,
we have been trying to reduce the number of women who have caesarian sections, but the goal we
set of a 23% rate was based on a regional target which has now been dropped because it was felt to
be arbitrary and unrealistic. Although we will continue to monitor our caesarian rate closely, we are
confident that all decisions to deliver a baby in this way have been in the best interests of ensuring
safe outcomes for our women and their babies.
Our overarching priority for maternity care is the safety of women and their babies. One of the
ways in which we ensure safety is to adhere to maternity care standards set by the NHS Litigation
Authority, also known as ‘CNST clinical risk management standards’. During the last year, we were
awarded Level 2 CNST, with a very high score. This means that we have been independently
assessed to ensure that our processes for managing risks are properly described in formally
approved documentation and are in use. The independent assessor has also recommended that we
apply soon for a Level 3 award, the highest possible level of CNST safety assessment in maternity
care.
Although we have not included maternity care in our set of quality improvement priorities for 2013/14,
we will continue to monitor a large number of things relating to childbirth in the form of a “Maternity
Dashboard”. These dashboards were developed by the Department of Health and Royal College of
Obstetricians and Gynaecologists and are now used widely. We have separate dashboards for the
two maternity units at Chichester and Worthing. These are reviewed every month at the Women’s &
25
Children’s Divisional Integrated Performance Review and key quality indicators are reported monthly
to the Quality Board and Trust Board.
The government has pledged that every woman will have one-to-one midwife care during labour and
birth. In 2013/14, we will introduce monitoring to ensure that we move quickly towards this goal. We
will also strive to meet new performance targets set by our local clinical commissioning group: to
ensure the appropriate presence of consultant staff on our labour wards and to ensure that women
are booked early for antenatal care so that any potential problems are detected and addressed
promptly.
Other quality areas where we have been striving for improvement
As well as working to address our goals for the quality improvement priorities set out in last year’s
Quality Account, we have also been striving to improve our performance in other ways. Below, we
summarise our quality achievements in some of these areas.
Quality achievements relating to CQUIN, Strategic Health Authority
and Local Priorities
Quality Domains and Indicators
2012/13
Goals
2012/13 Actual
(full year unless
otherwise stated)
Crude non-elective mortality
3.29%
3.24%
Hospital Standardised mortality ratio (HSMR)5
<100
96.7
Proportion of patients with hip fracture operated on within 36 hours
>90%
94.1%
Proportion of mothers having their babies delivered by caesarean section
<23.0%
24.7%
Proportion of mother requiring forceps for delivery
<15%
11.3%
Proportion of deliveries complicated by post-partum haemorrhage
<1%
0.70%
Establish
baseline
>90%
94.4%
Patients with Hospital Acquired MRSA infection
Patients with Hospital Acquired C. difficile infection
2 or less
75 or less
1
72
Number of moderate or severe drug errors or prescribing incidents
6 or less
4
Hospital acquired pressure ulcer prevalence (grade 2)
<213
120
Hospital acquired pressure ulcer prevalence (grade 3 and 4)
<20
4
Inpatient falls resulting in low / moderate harm
<533
481
Improving Clinical Outcomes
Patient Safety
Safety thermometer score (% of patients harm-free)
VTE (blood clot) risk assessments on all eligible patients
Healthcare Acquired Infections attributable to the Trust
•
•
93.4%
5 - HSMR figures in the table above relate to the 12 months to January 2013.
26
Quality Domains and Indicators
2012/13
Goals
2012/13 Actual
(full year unless
otherwise stated)
Inpatient falls resulting in severe harm
2 or less
2
Percentage of patients who have a falls assessment within 24 hours
>80%
90.9%
Friends and family score6
Establish
baseline
58
Realtime feedback on the hospital environment7
>75
75
Realtime feedback on assistance
>85
87
Realtime feedback on compassion
>87
88
Realtime feedback on communication
>75
77
Realtime feedback on the Trust overall
>90
92
Nutritional assessments undertaken within 24 hours
>80%
85.6%
Nutritional assessments undertaken within 7 days
>95%
95.4%
>85%
>85%
95%
95%
Patient experience
Internal Patient Environment Action Team (PEAT) compliance:
•
•
St Richard’s Hospital
Worthing Hospital
6 - Based on data collection on inpatient wards using the Real Time Patient Experience system November 2012 to March
2013. The calculation is made using the national methodology as follows: Proportion of respondents who would be
extremely likely to recommend the trust MINUS the proportion of respondents who would not recommend the trust.
7 - Realtime feedback scores are based on data collected on inpatient wards for the full year 2012/13. Targets were set
by the Trust Quality Board at the beginning of the year based on demonstrating improvements against initial baseline data
collection.
27
Quality achievements relating to the NHS Performance Framework
The table below shows key indicators demonstrating the Trust’s performance against the NHS
Performance Framework.
Indicator
2012/13
Goals
2012/13
Actual
>95%
96.45%
MRSA
2 or less
1
C Diff
75 or less
72
Referral to treatment - admitted - 90% in 18 weeks
>90%
92.03%
Referral to treatment - non-admitted - 95% in 18 weeks
>95%
96.21%
Referral to treatment - incomplete pathways – 92% in 18 weeks
>92%
92.40%
0 (under
achievement
threshold =
20)
10
Diagnostic test waiting times (tests in 6 weeks)
<1%
0.39%
Cancer: 2 week GP referral to 1st outpatient
>93%
96.76%
Cancer: 2 week GP referral to 1st outpatient - breast symptoms
>93%
95.24%
Cancer: 31 day second or subsequent treatment - surgery
>94%
97.64%
Cancer: 31 day second or subsequent treatment - drug
>98%
100%
Cancer: 31 day diagnosis to treatment for all cancers
>96%
98.74%
Cancer: 62 day referral to treatment from screening
>90%
92.55%
Cancer: 62 days urgent GP referral to treatment of all cancers
>85%
88.52%
Delayed transfers of care
<3.5%
2.7%
0% (under
performance
threshold
0.5%
0.02%
Four-hour maximum wait in A&E from arrival to admission, transfer or discharge
RTT delivery in all specialties (number of specialties outside 18 weeks)
Mixed sex accommodation breaches (as a proportion of consultant episodes)
The Enhancing Quality and Recovery Programme
The Enhancing Quality Programme now incorporates the Enhanced Recovery Programme and has
continued its development and expansion across a number of NHS Trusts as a model for large scale
change.
During 2012/13, we have participated actively in the Enhancing Quality programme, both in
maintaining progress with existing care pathways and helping to develop the approach in new clinical
areas that will be fully implemented in the coming year, including Acute Kidney Injury, High Impact
Innovations, Fractured Neck of Femur and Chronic Pulmonary Disease. Over the past year, we
have continued to make steady improvements across all the pathways that have been part of the
programme.
28
We have met fully the programme’s targets for heart failure and hip and knee replacements, and
have achieved steady improvement in the care of patients with pneumonia. The partial target for
pneumonia has been met though the full target is unlikely to be met in 2012/13 despite having
improved on the previous year’s excellent performance. The slight shortfall from meeting the full
target relates to a very small number of patients. A plan has been developed to ensure that the Trust
continues to improve its pneumonia care pathway as the project moves into the next phase.
We are on trajectory to meet the outcome targets for both reductions in pneumonia mortality and
heart failure readmission, achievements we are determined to maintain in 2013/14
Although the Trust is still submitting data related to the pathway for antipsychotic drug prescribing,
no performance targets were set in 2012/13 because of the introduction of the national dementia
CQUIN (a different approach to setting standards). The Trust has, however, met the requirement to
incorporate the antipsychotic drug criteria into the national data collection process.
Enhanced recovery, often referred to as ‘rapid recovery’, is a new, evidence-based model of care that
seeks to get patients fitter prior to major surgery so that they recover faster afterwards. The approach
relies on patients being partners in their own care, and, where possible, uses less invasive surgical
techniques, careful pain relief and optimal management of fluids and diet. Patients cared for in this
way typically experience fewer complications and go home earlier.
There are three groups of patients for whom we have introduced this enhanced recovery approach:
those having hip or knee replacements; patients needing colorectal surgery; and women having
hysterectomy operations.
In 2012/13, for hip and knee replacements, we met fully all data submission and quality standards as
well as two improvement targets related to patient information and early mobilisation.
For patients undergoing colorectal surgery, the improvement targets relating to information given to
patients before operation and carbohydrate loading (something that helps with ‘surgical fitness’) are
being met fully at Worthing Hospital and good progress is being made towards meeting the standards
at St Richard’s where the programme has only more recently been established.
The enhanced recovery pathway for women having hysterectomy operations is still at an early stage
of development but good progress is being made. We are meeting all data submission and quality
standards and are on track to meet the improvement targets related to information given to patients
before operation and once when they are discharged. Who was involved in the content of this report
and the priority setting?
29
Who was involved in the content of this report and the
priority setting?
The content of this report was agreed with the Trust’s Executive Team, Senior Clinical Staff (Clinical
Leaders Group) and the Trust Board. Our priorities for quality improvement in 2013/14 are based on
our Quality Strategy and follow consultation through our clinical divisions with staff, and with our other
stakeholders, including patients and their carers.
The report has been reviewed by our principal commissioner, Coastal West Sussex Clinical
Commissioning Group, by Healthwatch West Sussex, and by West Sussex County Council Health &
Adult Social Care Select Committee. They have been invited to review the report and their comments
are included below.
Statement of directors’ responsibilities in respect of the Quality
Account
The directors are required under the Health Act 2009 to prepare a Quality Account for each financial
year. The Department of Health has issued guidance on the form and content of annual Quality
Accounts (which incorporates the legal requirements in the Health Act 2009 and the National Health
Service (Quality Accounts) Regulations 2010 (as amended by the National Health Service (Quality
Accounts) Amendment Regulations 2011).
In preparing the Quality Account, directors are required to take steps to satisfy themselves that:
•
•
•
•
•
the Quality Account presents a balanced picture of the trust’s performance over the
period covered;
the performance information reported in the Quality Account is reliable and accurate;
there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to review to
confirm that they are working effectively in practice;
the data underpinning the measures of performance reported in the Quality Account is
robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review; and
the Quality Account has been prepared in accordance with Department of Health guidance.
The directors 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
4 June 2013
…………………………..Date………………………………………………………………Chair
3 June 2013
………………………….Date……………………………………………………………….Chief
Executive
30
Annex 1: Statements from stakeholders regarding
this Quality Account
Statement from Coastal West Sussex Clinical Commissioning Group
(CCG)
Thank you for sending Coastal West Sussex CCG a draft copy of your 2012/13 Quality Account.
The Quality Account has been reviewed and Coastal West Sussex CCG confirms that the account
demonstrates progress against the priorities identified for 2012/13. It provides information across the
three areas of quality: patient safety; patient experience, and clinical effectiveness and highlights an
ongoing commitment to improving quality of care. In general Coastal West Sussex CCG finds that
the account meets the national guidance and framework issued by the Department of Health letter
Quality Accounts: reporting arrangements for 2012/13 (dated 29th January 2013).
The Quality Account 2012/13 clearly highlights improvement areas in 2013/14 as well as how future
progress will be measured. It is positive to note that in light of the recommendations of the Francis
Inquiry Western Sussex Hospitals NHS Trust are reviewing many aspects of their systems and
processes so as to ensure that the individual needs of each patient are taken into consideration.
Western Sussex Hospitals NHS Trust has worked hard to improve quality. It is positive to note the
demonstrable improvements in many areas and in particular the prevention and control of infection.
The Quality Account clearly recognises the need to continue to build on these achievements.
Whilst noting the positive improvements that have taken place, Coastal West Sussex CCG looks
forward to the implementation of electronic discharge summaries across the organisation; an
improvement in the referral to treatment delivery consistently across all specialties and working with
Western Sussex Hospitals NHS Trust and other stakeholders in the local health economy to reduce
the 28 day readmission rate.
The Quality Account acknowledges the ongoing work required in order to continue to improve the
quality of services, including the reduction of avoidable mortality, provided at Western Sussex
Hospitals NHS Trust and Coastal West Sussex CCG looks forward to working collaboratively with
Western Sussex Hospitals NHS Trust in the attainment of these objectives over the coming year.
The continued focus on patient experience and improving outcomes in 2012-13 should continue to
improve the quality of services provided by Western Sussex Hospitals NHS Trust to the population of
Coastal West Sussex.
Coastal West Sussex CCG considers the published priorities appropriate for this organisation, and
will actively review these throughout the coming year.
May 2013.
31
Statement from Healthwatch West Sussex
Thank you for inviting Healthwatch West Sussex (HWWS) to provide a statement on the 2012/13
Quality Account for Western Sussex Hospitals NHS Trust (WSHT). As you may know, HWWS has
recently appointed its Board and is in the process of determining its final representation and liaison
arrangements with various strategic forums. Its commentary on Quality Accounts is therefore limited
in scope this year.
Two previous members of the West Sussex LINk (the predecessor organisation to Healthwatch West
Sussex) Stewardship Group have been elected as shadow public governors of the Trust and decided
against contributing to this commentary pending a more permanent liaison appointment by the
HWWS Board. Nevertheless Healthwatch has benefitted from expert commentary available to it from
a local participant.
I confirm that to the best of my knowledge the WSHT draft Quality Account contains accurate
information and commentary is provided below. The main interaction between HWWS and the
Trust over the past 6 months has been with regard to the PLACE (Patient Led Assessment of the
Care Environment) process. HWWS volunteer experience of this interaction has been positive with
volunteers utilized as Patient Assessors at St Richard’s and Worthing Hospitals. However HWWS
was not informed of Trust participation in the pilot phase of the PLACE programme which might have
led to beneficial outcomes through early collaboration.
The draft Account describes commendable Trust-wide activities to promote quality and safety as well
as involvement in statutory supervision and voluntary participation in almost every available national
clinical audit and improvement initiative. The introductory statement mentions that the Trust took top
prize at the 2012 HSJ patient safety awards for Board leadership. Significantly the Trust scored as
Excellent in all three of its Patient Experience Action Team (PEAT) categories for 2012. West Sussex
LINk surveys confirmed there were no serious concerns and good practice in evidence at Worthing
and St Richard’s Hospitals during this period.
The document refers to many national agencies and resources, such as Care Quality Commission,
HSCIC and NPSA, but does not offer website addresses for readers to access. The WSHT website
(provided on page 24) includes a list of inspection and monitoring agencies worthy of updating: the
home page of the NHS Litigation Authority has changed; the functions of the National Patient Safety
Agency (NPSA) transferred to the NHS Commissioning Board Special Health Authority in June 2012.
In accordance with the Department of Health Guidance on Quality Accounts, we trust you will include
these comments verbatim in WSHT Quality Account 2012/13 and would be grateful for sight of the
final submission.
Frances Russell,
Chair of the Board, Healthwatch West Sussex
32
Statement from the West Sussex County Council Health & Adult Social
Care Select Committee (HASC)
Thank you for offering the Health & Adult Social Care Select Committee (HASC) the opportunity
to comment on Western Sussex Hospitals NHS Trust’s Quality Account for 2012-13. Please find
HASC’s comments, based on feedback from James Walsh and myself, as the HASC liaison members
for WSHT.
We welcome the continued open dialogue and liaison arrangements between WSHT and the HASC,
and look forward to working with you in 2013-14. Key issues for the Committee that relate to WSHT
include: End of Life Care, A&E Services and the quality of services provided to NHS trusts to West
Sussex residents (which we hope will tie in with the Quality Accounts process for next year). We will
involve you in any discussions around these issues as and when appropriate.
The HASC liaison members for the year ahead will be appointed at the Committee meeting on 26
June 2013, so we will update you after that on our liaison arrangements with WSHT. I also look
forward to being updated on the status of your Foundation Trust application in the near future.
•
WSHT’s Quality Account provides a clear, readable and relatively concise summary of your
performance during 2012-13 and your plans for the future. The Trusts’ performance has been
very strong during the past year, but we welcome the fact that you are open about the areas
where performance needs to improve – and that you set out very clearly how you plan to address
these. The Quality Account sets out some stretching targets for the year ahead and is also open
and honest about the challenges that lie ahead. We hope that the Trust will continue to monitor
performance in a rigorous and transparent way once it has achieved Foundation Trust status.
•
We welcome your focus on patient safety and quality and your commitment to a positive
reporting culture for learning and improving from things that have gone wrong. You place a
strong emphasis on patient engagement, and the Quality Account shows how you have gathered
feedback and acted on this during the year. However, we would suggest that a more explicit
commitment to engaging and involving carers and families may be helpful in the future – as their
role is key, particularly in terms of patient support and discharge arrangements.
•
Your Quality Account clearly shows areas where performance needs to be improved and/or
maintained. We feel that some of the key issues for the year ahead are:
-
•
Mortality rates
A&E (meeting the 4-hour maximum wait from arrival to admission, transfer or discharge)
Business of hospitals and staffing levels
We understand that some of these require the whole health and social care system to work
together on, and are not just the responsibility of WSHT, but hope that you will continue to act as
a system leader and ensure that these are addressed during 2013-14. HASC would hope to be
able to support you in this, and we look forward to receiving updates on performance on these key
issues.
In terms of your priorities for the future, we particularly support your emphasis on patient safety
your plans to begin measuring the patient safety culture. Your approach to care, compassion and
communication – the dignity of patients and how they are cared for is critical to the population
33
you serve. We feel that it will be important for you to monitor and evaluate patients’ experience of
discharge, to include medicines management. HASC has heard some concerns during the year
relating to people’s experience of discharge, and hopes that WSHT will continue to work with the
wider system (i.e. Patient Transport Service, Adult Social Care) to ensure this improves.
Mrs Margaret Whitehead
Chairman, Health & Adult Social Care Select Committee
Response from Western Sussex Hospitals NHS Trust to statements from stakeholders
Western Sussex Hospitals NHS Trust welcomes the comments from its stakeholders and will take
note of these in its future quality work. No changes have been made to the draft Quality Account as a
result of comments received.
34
Annex 2: Report provided by external auditors
35
36
37
No
Yes
No
Cardiac Arrest
Cardiac arrhythmia HRM
Cardiothoracic transplant
No
Adult critical care ICNARC
CMP
Yes
No
Adult community acquired pneumonia –
BTS
No
Yes
Adult cardiac surgery ACS
Bronchiectasis – BTS
No
Adult Asthma – BTS
Bowel cancer – NBOCOP
Yes
National Clinical Audit and
Patient Outcomes Programme
(NCAPOP)
Acute Coronary Syndrome or Acute
Myocardial Infarction – MINAP
Name of audit
This list is in alphabetic order
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Was the Trust eligible to take
part
N/A
Yes
No
No
Yes
Yes
Yes
N/A
Yes
Yes
Did the Trust take part
N/A
Ongoing [Worthing]
40
Decision not to participate as
Trust already participates in
ongoing internal audits.
Clinical decision not to
participate
Ongoing [ All sites ]
Ongoing
Ongoing
N/A
100% [Worthing only]
Ongoing [ All sites ]
Percentage of data collection
completed
National Clinical Audits listed by the National Clinical Audit Advisory Group (2012-13)
Appendix 1
Appendix 1
38
39
Yes
Yes
Yes
Yes
Lung cancer – NLCA
National joint registry – NJR
Neonatal intensive and special care –
Yes
Heavy menstrual bleeding HMB
Yes
No
Health promotion in hospitals – NHPSA
Inflammatory Bowel disease - IBD
Yes
Heart failure – HF
Hip fracture database NHFD
No
Yes
Head and neck oncology – DAHNO
No
Fever in children – CEM
Fractured neck of femur – CEM
Yes
Falls and bone health – NAFBH
Yes
Diabetes in paediatrics – PNDA
Yes
Yes
Diabetes adults – ANDA
Epilepsy 12 – childhood epilepsy
Yes
Coronary Angioplasty
Yes
Yes
Chronic obstructive pulmonary disease –
COPD
No
Yes
Congenital heart disease
Paediatric cardiac surgery - CHD
Emergency use of oxygen – BTS
No
Comparative audit of blood transfusion
Emergency Laparotomy
Yes
National Clinical Audit and
Patient Outcomes Programme
(NCAPOP)
Carotid interventions – CIA
Name of audit
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Was the Trust eligible to take
part
Yes
Yes
Yes
Yes
Yes
Yes
N/A
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Tendering in process
Yes
Yes
Yes
Tendering in process
N/A
Yes
Yes
Did the Trust take part
100% [All sites]
Ongoing [All sites]
Ongoing [All sites]
100% [ Worthing only]
Ongoing [All sites]
29% [All sites]
N/A
Ongoing [All sites]
Ongoing [All sites]
100% [All sites]
100% [All sites]
41
100% [ Southlands only] – pilot
100% [All sites]
100% [All sites]
100% [All sites]
100% [All sites]
Ongoing [Worthing]
N/A
100% [SRH only]
Ongoing [Worthing]
Percentage of data collection
completed
40
Yes
No
Yes
No
No
No
Yes
No
No
No
No
Yes
Yes
No
No
Pain database
Parkinson’s disease
Potential donor
Prescribing observatory for mental
health POMH-UK
Psychological therapies
Pulmonary hypotension
Renal colic – CEM
Renal registry UKRR
Renal transplantation (NHSBT UK
transplant registry )
Schizophrenia NAS
Stroke national audit programme –
combined sentinel SINAP – SSNAP
Trauma – TARN
Vascular Surgery – VSGBI vascular
surgery database
No
Paediatric asthma – BTS
Paediatric pneumonia – BTS
Yes
Oesphago gastric cancer NAOGC
Paediatric intensive care – PICANet
No
National Clinical Audit and
Patient Outcomes Programme
(NCAPOP)
Non invasive ventilation – BTS
NNAP
Name of audit
Yes
Yes
Yes
No
No
No
Yes
No
No
No
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Was the Trust eligible to take
part
Yes
Yes
Yes
N/A
N/A
N/A
Yes
N/A
N/A
N/A
Yes
Yes
Yes
Yes
N/A
Yes
Yes
Yes
Did the Trust take part
100% [All sites]
Ongoing [All sites]
42
SRH partial completion.
Coordinators on both sites from
2013
N/A
N/A
N/A
100% [Worthing only]
N/A
N/A
N/A
[All sites] n= 83
100% [Worthing only]
Ongoing [Worthing]
100% [All sites]
N/A
100% [All sites]
Ongoing [All sites]
Ongoing
Percentage of data collection
completed
41
Yes
Yes
Yes
No
Yes
Child Health
Maternal infant and perinatal
Patient outcome and death –
NCEPOD
Suicide and homicide in mental
health
Elective surgery ( PROMS)
Was the Trust eligible to take
part
Yes
National Clinical Audit and
Patient Outcomes Programme
(NCAPOP)
Asthma Deaths
Name of audit
Confidential enquiries
Yes
N/A
Yes
Yes
Yes
Yes
Did the trust part
N/A
93.3% [All sites]
100% [All sites]
100% [All sites]
100%
43
Percentage of data collection
completed
Regular audit meetings take place to review the data on the NHFD along with monthly mortality and morbidity
meetings which are reported to the Trust Board.
Monthly meetings take place to review all MINAP cases.
Staff who have not been trained should not be allowed to administer blood. Western Sussex Hospitals NHS
Trust (WSHT) hospitals should also audit practice in non-standard settings such as ITU, PICU, theatre recovery
and on day units to ensure that standards of bedside administration and patient care are consistent throughout
all areas. WSHT report non-compliance with any key audit standards as an incident and investigate using Root
Cause Analysis, with appropriate corrective and preventative action.
Regional report published, waiting for NPDA to release local results.
WSHT had results higher than national average results for some of the audit criteria. The percentage of patients
currently using oxygen with no prescription or bedside order was higher than national average (51.7%) 62.5%.
The audit of oxygen is to be audited on a continuous basis.
National Hip Fracture Database
MINAP
Comparative audit of blood transfusion
Diabetes in paediatrics NPDA
Emergency use of oxygen - BTS
WSHT are considering waiting times for new neurology referrals in order to meet NICE guidelines. Formal
documentation of patient suitability prior to initiating dopamine agonists at each review to be reassessed.
Information provided by Parkinsons UK to be available in clinic.
Parkinson’s Disease
44
In phase one of this audit, 154 women were recruited at WSHT. Phase one was a baseline questionnaire in
st
st
clinic [1 February 2011 to 31 January 2012]. Phase two in progress, final report to be published later in the
year.
results were discussed within the WSHT reporting group for falls.
Main points of action
Heavy menstrual bleeding HMB
Audit title
Fall and bone health NAFBH (inpatient falls pilot)
WSHT are concentrating on two performance indicators : (i) Appropriate 1 clinical assessment – WSHT to hold
st
divisional discussions about feasibility & frequency of 1 seizure clinic. (ii) No database or register of children
with epilepsies - WSHT to establish a database of children with epilepsies.
There was no full national audit of falls and bone health in April 2012 to March 2013. WSHT took part, however,
in the RCP’s pilot audit focusing on falls prevention for inpatients, and the care provided following an inpatient
fall. The RCP did not release specific reports for the individual hospitals that participated in the pilot. The local
st
Continuing surveillance of joint infections is undertaken through the infection control committee.
National Joint Registry
Epilepsy 12 ( Childhood epilepsy )
Main points of action
Audit title
Actions resulting from reviews of National Clinical Audits
Appendix 2
Appendix 2
42
43
Improvement of documentation of communication:
• with the patient and/or welfare attorney
• with the patients relatives and/or their friends
• where appropriate, improve the documentation of the members of multidisciplinary involved in the decision
• Improve the completion of the review date section, especially when this is inappropriate. In these instances “no
review date“ should be documented.
Briefing sessions are to be organised within the divisions to feedback the findings and re-emphasize the areas that need to be
improved.
During induction for all F1 and F2 doctors there should be a compulsory session for diabetes.
DNAR documentation
Diabetes, Prescribing and Assessment of
Mortality COPD
46
Results show that many patients having a stroke are appropriately screened for mood disturbance (50%) and cognitive
impairment (59%) at an early stage (within 6 weeks) using a validated screening tool. A number, however, particularly those
with communication impairment, are not. In order to address these gaps, the action is to evaluate assessment tools in
dysphasia and ensure that mood and cognitive assessments are embedded in standard patient screens. There will be ongoing
discussion with the Speech and Language Team about how best to approach mood screening in patients with primary
communication difficulties.
Increase awareness that a full medications review needs to be done after a fall. Posters, Emails, Lectures will be used to
inform doctors to review medications after a fall.
Since the audit, block half hourly teaching sessions now take place on the Acute Medical Unit every 3 months - these are open
to all staff trained or HCA’s. There is now a newsletter in place, circulated quarterly to all clinical/ward areas. Link nurse
sessions also have teaching input quarterly in Diabetes Centre which are open to all nursing staff. There is a ‘hypo’ initiative
being set up Trust wide which will incorporate teaching and discuss any incidents of hypoglycaemia that have occurred.
A formal audit of oxygen administration has been prioritised prior to medical review.
Screening Patients after Stroke for Mood
Disturbance and Cognitive Impairment
Audit of Medicines in Falls patients in
Hospital June 2012
Use of Ward/Unit Hypoglycaemia Box
Main points of action
Audit title
Actions resulting from reviews of local clinical audits 2012-13
Appendix 3
Appendix 3
44
Audit to assess the proportion of elective
cholecystectomies being performed as day
case procedures
Audit to assess the management of right
Management of Acute Pancreatitis
Audit on management of patients with
early rectal cancer with TEMS procedure
47
Senior doctors and particularly consultants should ensure during post take round that smoking history is recorded
appropriately and cessation advice given where indicated. Junior doctors should be given face to face feedback to improve
compliance. Training on smoking history and cessation advice should be part of induction for all new doctors involved in
clerking of patients.
All patients with biopsy proven early rectal cancer should undergo endoanal ultrasound investigation pre-operatively (in
conjunction with CT and MRI). Ensure patients with T1 disease on pre-operative imaging are offered TEMS for curative
resection (to minimise high rates of salvage surgery/resection).
Acute pancreatitis proforma for documentation of scoring system and management for every patient admitted with acute
pancreatitis. Patients with severe pancreatitis can be treated in ESCU ward with daily review by Outreach Team and
escalation to HDU/ITU if necessary. Use of antibiotic prophylaxis for patients with acute pancreatitis and deranged LFT’s.
Careful selection of laparoscopic cholecystectomy cases for day surgery. Day case laparoscopic cholecystectomy patients
were mixed with major cases increasing the chances of late operation and possible cancellation, therefore it is suggested that
there is a dedicated day case list for these patients.
All patients must have a pregnancy test documented in their notes. Increased multi-disciplinary team working between
History of smoking in health records
Prescription of Frusemide in Acute Heart
Failure
All patients must have a set of observations prior to transfer and leaving AMU to wards. If change in Early Warning Score,
nurses to inform doctors and this must be documented as a review.
Creation of a transfer checklist prior to transfer to include: pre-transfer observations and outstanding investigations.
Ensure there are more formal teaching sessions on prescribing, particularly for junior doctors.
A poster will be placed in AMU to act as a reminder so that the indicator diseases are not forgotten by junior doctors when
clerking new admissions,.
A drug chart layout has been amended to provide a separate section for insulin prescribing, including pre- printed ‘units’.
Continuing education within the medical faculty about the importance of early identification of diabetic foot problems,
including emphasis on the need to examine all diabetic patients’ feet on admission.
All patients should be provided with the nationally recognised NPSA methotrexate monitoring cards.
Ensure continued education for junior doctors on safe prescribing of MTX.
Main points of action
Patient safety transferring patients from
AMU to other wards
Methotrexate Prescribed for the
Treatment of Psoriasis and Inflammatory
Arthritides
Audit of Diabetic Care of Medical Patients
HIV testing in medical admissions
Diabetic Control and the Feet
Audit title
45
Main points of action
Good practice identified
Excellent service was identified.
Second stage Caesarean Section for failed
instrumental delivery
Colposcopy unit – patient satisfaction
survey
48
Introduce a care pathway for all femoral shaft fractures and periprosthetic fractures in the elderly. Introduce the guidelines to
the Trauma and Orthopaedic department.
Indentify potential delays / changes in operating list order early to a allow patients to drink as necessary.
Ensure correct pre-operative information is given by pre-assessment teams.
Compliance with completion of the VTE form was good and translated in most cases to an appropriate
prescription/appropriate withholding of the correct Low Molecular Weight Heparin at the correct dose. Need to improve the
quality of completion of the VTE forms particularly in accurately identifying risk factors.
Continue to ensure that consultant has been involved in decision making for all elective Caesarean Sections. Look at options
for encouraging women to consider Vaginal Birth after Caesarean.
Improved documentation of Consultant Obstetric involvement in care of patients while on ITU and of discussions and
involvement of other clinical specialists in decision to transfer.
Audit title
HDU/ITU admissions in obstetrics
Elective Caesarean bookings
Pre-operative fasting in Maxillofacial
patients
Haematology VTE Prophylaxis Audit
Parental satisfaction with pre-op for Day
Surgery
Audit of Femoral Fractures
Is the HER2 Status Known when Decision
for Systemic Treatment is Being Made at
Breast Cancer MDT’s
Inadvertent peri-operative hypothermia
Improve documentation on anaesthetic record cards
o Bed managers to look for available beds, even for patients who have been “booked” for critical care
o Ensure good communication between surgical team and anaesthetic team.
Continue monitoring HER2 status in women with Breast Cancer. Avoid delays in HER2 testing in all patients, as it represents a
powerful tool at the Breast Multidisciplinary Meetings. Consider new therapies against HER2 for treatment of Breast Cancer
and keep local guidelines up-to-date according to the latest literature
Posters on all fluid cabinets stating that 20% of patients arrive to recovery hypothermic, and that more than 500mls of fluids
requires warming, and more than 30mins of anaesthetic time requires a Bair Hugger. It is suggested that the presence of
tympanic thermometers in every anaesthetic room would encourage the documentation of temperature prior to induction
and during the operation. Recovery staff are generally performing well, but a reminder that patients should not be discharged
until they are >36°C.
Current practice is working well and giving a very high level of satisfaction with pre-operative information.
general surgery and gynaecology. The on-call arrangements in gynaecology may need to be re-structured. Currently the
consultant on call has to cover labour ward, leaving limited time to see patients under joint surgical and gynaecology care.
To re-audit with the introduction of the right iliac fossa pain pathway to see if it reduces the length of stay and increases the
number of patients resenting on the acute surgical intakes who are also seen by gynaecologists.
Good practice identified.
iliac fossa pain in women of child bearing
age
Audit of Satisfaction with Pre-Operative
Parent and Patient Information - Day
Surgery Unit
Post-operative location of patients
undergoing emergency laparotomy
Main points of action
Audit title