CircleNottingham
Quality Account
2013/14
CircleNottingham Quality Account 2013/14
3
Contents
Part one
About the Quality Account6
About CircleNottingham7
Statement from the General Manager8
Engagement
9
Part two
Achievement against quality improvement priorities for 2013/1412
Review of quality performance for 2013/1414
Quality improvement priorities for 2014/1520
Mandatory statements23
Part three
Clinical unit Quality Accounts32
• Dermatology32
• Cardiology, respiratory and vascular
39
• Radiology45
• Orthopaedics52
• Endocrinology and rheumatology
58
• Gynaecology65
• Day case
71
• Endoscopy78
• Digestive diseases
84
Part four
Statement from the Patient and Public Engagement Group92
Statement from NHS Rushcliffe Clinical Commissioning Group 93
Statement from the Joint Nottingham and Nottinghamshire
Health Scrutiny Committee
95
Jargon buster96
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CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
5
Part one
Patient, CircleNottingham
“Staff were awesome; every single one of
them. They were very good at making me
feel at ease. All showed compassion and
commitment, professional and friendly.”
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CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
About the
Quality Account
About
CircleNottingham
The Health Act 2009 requires all providers of healthcare services to NHS patients to publish
an annual report about the quality of their services; this report is called a Quality Account.
CircleNottingham belongs to a group of companies owned by Circle, and is the largest
independent sector treatment centre in Europe. Circle is an employee co-owned partnership
with a social mission to make healthcare simpler, better and smarter value for patients.
Circle is co-founded, co-run, and co-owned by clinicians and healthcare professionals.
Because the clinicians and healthcare professionals who work for Circle have a sense of
ownership for their work, they are empowered to put patients first in everything that they
do. Circle’s approach is based on the premise that clinicians are best placed to decide how
to deliver the best care for patients, and our credo commits us to being ‘above all, the agents
of our patients’.
The primary purpose of a Quality Account is to enhance organisational accountability to the
public, to engage boards and leaders of organisations in fully understanding the importance
of quality across all of the healthcare services they provide, and to promote continuous
improvements on behalf of their patients.
A Quality Account must include:
• a statement summarising the registered manager’s view of the quality of services provided
to NHS patients.
• a review of the quality of services provided over the previous financial year (2013/14).
• the quality priorities for the forthcoming financial year (2014/15).
CircleNottingham is extremely proud to present its Quality Account for 2013/14. Our
clinical units have worked very hard to produce their own quality accounts that represent
how motivated and driven they are to improve services for their patients.
We have also worked closely with our commissioners, the Patient and Public Engagement
Group, CircleNottingham’s Executive Board, and CircleNottingham’s Clinical Governance and
Risk Management Committee, to produce a Quality Account that provides our patients and
the general public with information that demonstrates our commitment to quality as the
first and foremost priority in our organisation, and provides the reader with a comprehensive
insight into who we are and what we do.
The services delivered at CircleNottingham, as with other Circle hospitals, are divided into
separate business units, named clinical units. Each clinical unit is led by a doctor, nurse and
administrator, and the unit has the freedom and authority to take decisions that impact
upon patient care. They are also responsible for managing their own budgets. In this way,
power is devolved to the front line, and decisions are taken as close as possible to patients.
Our success as a company does not lie in a small group of expert managers at the top of
the company, but in a large community of expert innovators at the grass-roots. In this
way, we maximise our effectiveness and harness the collective wisdom of a large group
of people to offer the best possible solutions for our patients.
The core services provided at CircleNottingham include:
• dermatology
• endocrinology
• surgical terminations
• hepatology
• rheumatology The additional services provided at CircleNottingham include:
• respiratory
• vascular
• digestive diseases
• urology
• orthopaedics
• gynaecology, including three colposcopy/hysteroscopy treatment rooms
• pain services
• light therapy
• day case surgery, comprising five main theatres, three skin surgery theatres, a recovery
ward and discharge lounge
• endoscopy, comprising four endoscopy suites
• diagnostic services, including one analogue and two digital x-ray machines, magnetic
resonance imaging (MRI) and computerised tomography (CT) scanners, ultrasound (US)
scanners and a DEXA scanner
• eleven-bed Short Stay Unit with disabled and bariatric facilities
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CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
Statement from the
General Manager
This year’s Quality Account demonstrates how during
2013/14, CircleNottingham successfully mobilised and
innovated both our core and additional services to support
an ambitious local and strategic agenda aimed at delivering
integrated care to the local healthcare economy.
We are extremely proud to have been awarded a further five-year contract to continue to
deliver services from the Nottingham NHS Treatment Centre and community sites, and are
delighted that 14 clinical commissioning groups commissioned our services through a new
Standard Acute Contract.
Our challenge has been to maintain a high-quality service, while mobilising this new contract.
We are delighted to report that clinical units have continued to deliver high-quality, safe care
with efficient and effective clinical outcomes, while continuously improving and redesigning
patient services in line with commissioning requirements. The clinical units have demonstrated
both their achievements and reflections in their individual quality accounts, and we can
identify other achievements, including our successful ISO 27001 accreditation and successful
completion of the Information Governance Toolkit.
Our key stakeholders, including members of our Patient and Public Engagement Group,
have aligned themselves to clinical leadership teams and, along with front line staff, have
attended partnership events. Patients’ voices have been heard. Local and national lessons
from both internal feedback and external reports, such as Francis, Berwick and Keogh,
Cancer Peer Review and CQUIN outcomes, have all been embraced. Improvements
have been identified and implemented using our Circle Operating System methodology.
New developments such as the design, construction and mobilisation of our 11-bed
Short Stay Unit now enable us to deliver care for a wider group of patients who require
additional clinical and social support. New technology, such as Telemedicine, is allowing
us to reduce inappropriate hospital attendances and deliver care closer to our patients.
Capturing our patient feedback innovatively enables real time improvements. With the
credo at the heart of our evolution, clinical leadership continues to grow. A redesigned
Executive Board framework has given us a new platform to deliver our vision and strategic
priorities. We continue to work very closely with our patients and carers, our Patient and
Public Engagement Group, GPs, front line staff and other stakeholders to redesign services
for the future. We remain committed to develop integrated pathways that keep the patient
at the centre and bring high-quality healthcare closer to our patients.
This Quality Account has been ratified by our Executive Board and we confirm that the
content reflects a balanced view of the quality of our services and we believe, to the best
of our knowledge, that the information contained in this document is accurate and informative.
Rachael Magnani
General Manager
CircleNottingham
EngagementPositive feedback
During the process of preparing our Quality Account for
2013/14, we felt that it was really important to have an
integrated approach, whereby no one view was more
important than another.
We consulted with our staff at partnership events, engaged patient and public views, and
scanned the NHS landscape. We also discussed quality priorities with our commissioners
at our quality review meetings, general practitioners via our primary care manager, and
other stakeholders during the course of the financial year. As a company, we also wanted to ensure we had one voice, one vision, one team. Individual
Quality Accounts were developed by each clinical unit, but also collective views of the Board
and its sub-committees were sought. We have used our quality priorities to influence the
corporate quality objectives, and have undertaken streams of work, such as Stop the Line
and Compassion in Care, across all of the Circle hospitals and intend to continue this
going forward.
Our approach was multi-dimensional; we wanted to take a snapshot of the whole year’s
data and effectively consider all information available to us. We wanted our priorities to
be holistic so that our quality priorities could build on the existing excellent work delivered
in the previous financial year.
• Benchmarking
against sister facilities
• Circle Operating
System (COS) sessions
• 360º appraisals
• Staff Friends and Family Test
• Quality service review
• Board and subcommittees
• Partnership events
Partners
NHS
priorities
• Commissioning intentions
• Francis Report
• Integrated services
• Quality requirements
in NHS contract
• Health and
wellbeing campaigns
• Focus groups
• Patient story at Board
• Friends and Family Test
• Patient hour – clinical units
using patient feedback to
inform decision-making
• Patient and Public Engagement
Group members linked to
clinical services and participate
in service improvement
Patient
Circle
priorities
• Leadership 40
• Transparency of
clinical outcomes
• Building pathways with
primary and social care
• Continuous quality
improvement (COS)
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CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
Part two
Patient, CircleNottingham
“Environment was excellent!
Comfortable waiting areas,
excellent facilities and very clean.”
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CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
13
Achievement against quality
improvement priorities for 2013/14
Quality domain
Our quality priorities for 2013/14
Success measures for 2013/14
2013/14 progress
Status
Patient experience
‘Simply the best patient experience’
We promise to listen to what our patients want
and use the feedback to continually enhance the
patient experience
• A minimum return rate of 20% will be achieved
in relation to patient feedback cards
• The treatment centre will achieve an average net
promoter score (NPS) for the financial year that will
feature in the top quartile for the region
• We have achieved an average response rate of 22.25% for 2013/14
• We have collected feedback from over 45,000 patients during 2013/14
• We have an average NPS of 83.4
Achieved
‘No decision about you without you’
• The Right Care Decision Aid will be piloted
We will continue to empower our patients; decisions
about your care will be based on a combination of your
experience of your condition and your clinician’s expertise
• The quality improvement priority will be carried forward and incorporated into our 2014/15 programme
of work
2014/15 programme
‘Right first time’
Right appointment, right clinician, most
convenient location
• Text reminders for appointments will be piloted
• Increased access to clinics in the community will
be implemented
• Unnecessary attendances will be reduced
• The quality improvement priority will be carried forward and incorporated into our 2014/15 programme
of work
2014/15 programme
‘Excellence delivered’
We will make sure that our people have the right
knowledge and skills to deliver the best possible care
• The NHS Staff Survey will be undertaken
• A supervision framework will be developed and
implemented. Compliance against policy will
be reviewed
• The staff Friends and Family Test has been introduced and the quality improvement priority will be carried
forward and incorporated into the 2014/15 programme of work
• A supervision framework has been developed and implemented
2014/15 programme/
Achieved
Patient experience,
patient safety and
clinical effectiveness
‘Caring for you and caring about you –
see the person in the patient’
We promise to make sure that you get the right clinical
care provided by compassionate and caring staff
• The Patient First Compassion in Care Framework
will be audited monthly
• A falls screening tool will be developed, piloted
and implemented for patients over 75 years
• Ninety per cent of direct hire staff will undertake
a dementia awareness programme
• Ninety per cent of direct hire clinical staff
(including healthcare assistants) will be trained
in the principles of the Mental Capacity Act 2005
• A patient information pod will be introduced
and evaluated
• The relevant recommendations from the Francis
Report 2013 will be implemented
• A compassion and care audit tool has been developed and is in place within each clinical unit in the
treatment centre. Monthly compassion and care audits are undertaken by each clinical unit, and the
outcome and learning is discussed at the lead nurse meeting and presented at the Clinical Governance
and Risk Management Committee quarterly
• A falls screening tool has been developed and is in place within the endoscopy clinical unit. A staff training
package has been developed and implemented within the clinical unit. A standard operating procedure has
been developed and embedded. The quality improvement priority will be carried forward and incorporated
into the 2014/15 programme of work
• Dementia and Mental Capacity Act (MCA) Training are delivered as part of the induction programme for
all relevant staff, and we have recently introduced Educare, an online training programme to supplement
our existing mandatory training. Seventy-five per cent of all relevant staff have received Dementia and
MCA Training
2014/15 programme/
Achieved
Patient safety
‘Safety first every time’
Your safety will be our first priority
• We aim to have zero ‘never events’
• There will be repeat audits around the World Health
Organisation (WHO) surgical safety checklist in day
case to demonstrate improved compliance
• A WHO audit will be undertaken within skin surgery
• Applicable NICE guidance will be implemented
and audited
• We have had zero ‘never events’ during 2013/14
• WHO surgical safety checklist audits are undertaken monthly in the Day Case Unit
• WHO cultural audits are undertaken monthly in the Day Case Unit
Achieved
Clinical effectiveness
‘Better than the rest’
We will continually improve the quality of our services
by demonstrating that we both meet and exceed
national peer review standards
• Compliance with JAG accreditation will be maintained
• ISO accreditation will be maintained
• Skin cancer peer review accreditation will
be maintained
• JAG accreditation has been maintained
• ISO accreditation has been maintained
• The Skin Cancer Peer Review Accreditation has been maintained
Achieved
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CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
Review of quality
performance for 2013/14
The top five incident categories for 2013/14 are detailed below, and we have used this
information to inform our quality improvement priorities for 2014/15:
Best clinical outcomes
Incident reporting
At CircleNottingham, we believe that incident reporting provides a unique and valuable
opportunity to learn from our mistakes, and allows us to implement prompt and effective
safety solutions. We recognise that in order to have both a positive and informative
reporting system, we need to maintain a culture where staff feel able to report incidents
without fear of reprisal or blame.
An organisation with high incident reporting is a mark of a ‘high reliability’ organisation. Research shows that organisations with significantly higher levels of incident reporting are
more likely to demonstrate other features of a stronger safety culture, such as a high patient
satisfaction rate, positive peer review assessments, and a low number of clinical negligence
claims. Our commitment to reporting demonstrates a commitment to our patients and
their safety. This is recognised by the Care Quality Commission’s (CQC) Essential standards
of quality and safety, and further reinforced by the Report of the Mid Staffordshire NHS
Foundation Trust chaired by Robert Francis QC (February 2013). An organisation with a
high reporting rate of no harm incidents is a safe place to be.
Our staff reported a total of 2,173 incidents in 2013/14, as opposed to 2,109 incidents in
2012/13; this represents an increased reporting rate of 3% year on year. Incident reporting
represented 1% of our annual activity for 2013/14, which meets our internal targets of 0.7%
for outpatient services and 2% for day case.
Access, appointment, discharge 34%
Patient information (records/test results) 33%
Treatment and procedure 12%
Consent, confidentiality or communication 12%
Clinical assessment 9%
Serious incidents and never events
Serious incidents are defined as ‘incidents where care management failures are suspected,
which result in serious neglect, serious injury, major permanent harm or death (or the risk
of) to a patient as a result of NHS-funded healthcare’. One serious incident was identified
during 2013/14 relating to a safeguarding issue.
Never events are defined as ‘serious, largely preventable patient safety incidents that should
not occur if the available preventative measures have been implemented’. There were no
never events during 2013/14.
Safety alerts
Alerts issued via the Central Alerting System (CAS) relate to key safety issues that have
the potential to cause harm if not acted upon promptly. Safety alerts are an important
source of information which enables us to ensure that the safety of our clinical services
is our first priority. 240
220
200
Timely and effective implementation of safety alerts form part of the CQC’s Essential
standards of quality and safety. Failure to implement safety alerts could result in incidents,
complaints, claims and/or inquests, and have a significant impact on both staff morale and
patient confidence.
180
160
140
CircleNottingham received 221 safety alerts during 2013/14; 26 of which were applicable
to all/some of the services that we provide; 4 NHS England patient safety alerts, 2 medical
device alerts, 7 drug alerts and 13 chief medical officer alerts. 120
2012/13
2013/14
100
80
A
M
J
J
A
S
O
N
D
J
F
M
All CAS alerts were sent to the clinical units within 24 hours of receipt; they were actioned
and closed within the relevant timescales.
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CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
Best patient experience
Review of quality
performance for
2013/14
Complaints, concerns, comments, compliments and PALS enquiries
Claims
Three claims against CircleNottingham were closed during 2013/14; two were withdrawn
and one resulted in a settlement.
Continued
Patient surveys
At CircleNottingham, we believe that patient feedback is essential as it provides a rich
source of information about the quality of the services we provide. As an organisation,
we have set out the key principles in our credo to ensure we listen and act upon what
our patients tell us. The most effective way has been through the development of a rapid
response card providing real time information which is promptly acted upon by the clinical
teams. During 2013/14, we also introduced electronic tablets on each of our clinical units
so that patients have increased opportunity to feed back about our services.
NPS
Response rate
21
18
20
23
26
22
26
26
20
21
20
24
82
82
84
83
84
82
84
83
84
84
86
83
The net promoter score (NPS), more commonly known as the ‘Friends and Family Test’,
has been well established at CircleNottingham since 2012/13. The standard question
that we use is: “How likely is it that you would recommend us?”, and respondents indicate
this likelihood on a five-point rating scale. Those indicating ‘extremely likely’ are promoters;
those indicating ‘unsure, unlikely or not at all’ are detractors; and those indicating ‘likely’
are passively satisfied or neutral. The NPS is the difference between the number of users who
are extremely likely to recommend our services (promoters) minus the number of users who
would not (detractors). A score of 75 or above is considered quite high. During 2013/14, our
average NPS was 83 and we had a good response rate from our patients.
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
At CircleNottingham, we place feedback from our patients at the very heart of our
service and utilise this feedback to ensure that we are maintaining high standards of
care. We operate a complaints process that responds flexibly, promptly and effectively
to the justifiable concerns of complainants, which therefore enables us to address
unacceptable practices promptly, support complainants effectively, and promote
public confidence in our services.
353 pieces of feedback were received during 2013/14; comprising 89 complaints,
8 concerns, 40 comments, 170 Patient Advice and Liaison Service (PALS) enquiries,
and 46 compliments.
PALS enquiries 48%
Complaints 25%
Compliments 13%
Comments 12%
Concerns 2%
Complaints and concerns represent 27% of the feedback we received during 2013/14,
as opposed to 37% in 2012/13. We have also seen a significant increase in the number of
PALS enquiries we have received, from 73 in 2012/13 to 173 in 2013/14. This is not incidental
and is reflective of the excellent work that we have been doing to resolve patient, family
and carer complaints and concerns as early as possible. This ensures our patients receive a
prompt response to the matters they have highlighted, and we aim to respond to all PALS
enquiries within 24 hours. We also strive to provide support for those patients who feel
they do not want to make a formal complaint at that stage of their care.
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CircleNottingham Quality Account 2013/14
Review of quality
performance for
2013/14
CircleNottingham Quality Account 2013/14
The comparison data demonstrates that our approach is working extremely well.
We continue to deal with increased feedback from our patients, families and carers,
while our complaint and concern numbers reduce year on year.
The top five themes from complaints and concerns during 2013/14 are as follows, and
we have used this information to feed into our quality improvement priorities for 2014/15:
Continued
2012/13
2013/14
2013/14 2012/13
Complaints
Concerns
71
94
89
94
89
74
40
Concerns
2011/12
PALS enquiries
50
46
8
23
73
170
Clinical treatment 41%
Appointments/delay/cancellation/waiting times 28%
Communication 16%
Attitude and behaviour 9%
Test results 6%
Compliments
Complaints
Comments
67
23
8
19
20 CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
Quality improvement
priorities for 2014/15
Quality domain
Our quality priorities for 2014/15
Success measures for 2014/15
Why this is important to us…
Monitoring
and reporting
responsibilities
Patient experience,
patient safety and
clinical effectiveness
‘Simply the best patient experience’
We will continue to grow our services and expand
our capabilities to meet the needs of our patients
• Deliver inpatient activity, maximise bed utilisation
• Transfer rheumatology day case
• Introduction of head and neck service
• Development of new outpatient services
• We want to demonstrate that we actively listen to what you and your carers want from your healthcare service
• We want you to know that we care about your experience and that we are committed to building upon the
excellent services we already deliver
• We want to continually assure ourselves that the services we offer deliver excellence every time
• We want to demonstrate that we are your provider of choice
Executive Board
‘No decision about you without you’
We will continue to empower our patients; decisions
about your care will be based on a combination
of your experience of your condition and your
clinician’s expertise
• The Right Care Decision Aid will be piloted
• We believe you should be an equal partner in making decisions about your care
• We will provide you with the knowledge and expertise to assist you in making a shared decision
• We will help you work through your choices and voice your expectations
• We will honour your choice and support you in your ongoing care
Executive Board
‘Right first time’
Right appointment, right clinician, most
convenient location
• Text reminders for appointments will be piloted
• Increased access to clinics in the community will
be implemented
• Unnecessary attendances will be reduced
• We want to ensure that you only attend for an appointment when you absolutely need to
• We are committed to making sure that you see the right clinician at the right appointment in the best
location for you
Executive Board
‘Better than the rest’
We will continually improve the quality of our services
by delivering our national and local Commissioning
for Quality and Innovation (CQUIN) initiatives
for 2014/15
National CQUINs
1. a) Friends and Family Test (FFT) – implementation
of staff FFT
b) FFT – phased expansion
c) FFT – increased or maintained response rate
• We want to support safe and effective patient care, stimulate continuous improvement in processes
and patient outcomes, and maintain your confidence in our services
• We want to continually assure ourselves that the services we offer deliver excellence every time
• We want to demonstrate that we are your provider of choice
Executive Board
2. a) Dementia – screening tool
b) Dementia – clinical leadership
Local CQUINs
3. Reducing falls through improved intervention
(year one of five)
4. Improve patient experience through improved
complaints management
5. Transfer of care
6. Data sharing
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CircleNottingham Quality Account 2013/14
Patient, CircleNottingham
“Amazing treatment; very
kind; good bedside manner.”
CircleNottingham Quality Account 2013/14
23
Mandatory statements
Review of services
During 2013/14, CircleNottingham provided and/or sub-contracted five core and a number
of additional NHS services. CircleNottingham has reviewed all the data available to them
on the quality of care provided in all of these NHS services.
The income generated by the NHS services reviewed in 2013/14 represents 100%
of the total income generated from the provision of NHS services by CircleNottingham
for 2013/14.
Participation in clinical audits and
national confidential enquiries
During 2013/14, 11 national clinical audits and no national confidential enquiries
covered NHS services that CircleNottingham provides.
During that period, CircleNottingham participated in 100% of 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 CircleNottingham
was eligible to participate in, actually participated in, and for which data collection was
completed during 2013/14, are listed below alongside the number of cases submitted
to each audit or enquiry as a percentage of registered cases required by the terms of
that audit or enquiry.
Name of national clinical audit/
national confidential enquiry
National Clinical
Audit and Patient
Outcomes
Programme audit?
Participated
Yes/no?
If yes, percentage
of cases submitted
Medical and surgical clinical outcome review programme:
National confidential enquiry into patient outcome and death
Yes
Yes
100%
Non-invasive ventilation – adults
No
Yes
100%
Severe sepsis and septic shock
No
Yes
100%
Bowel cancer (NBOCAP)
Yes
Yes
100%
Oesophago-gastric cancer (NAOGC)
Yes
Yes
100%
National Cardiac Arrest Audit
No
Yes
100%
National Vascular Registry
Yes
Yes
100%
Pulmonary hypertension (Pulmonary Hypertension Audit)
No
Yes
100%
Inflammatory bowel disease
Yes
Yes
100%
National Chronic Obstructive Pulmonary Disease
Audit Programme
Yes
Yes
100%
Rheumatoid and early inflammatory arthritis
elective surgery (National PROMs Programme)
Yes
Yes
100%
Total
11
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CircleNottingham Quality Account 2013/14
Mandatory
statements
Continued
CircleNottingham Quality Account 2013/14
The reports of 11 national clinical audits were reviewed by the provider in 2013/14,
and CircleNottingham intends to take the following actions to improve the quality
of healthcare provided:
Name of local clinical audit
• Continue to proactively support all clinical units to ensure participation in national
clinical audits and national confidential enquiries where eligible.
• Encourage and promote learning from national clinical audits and national confidential
enquiries where they are applicable to the services we offer.
• Share the outcome of national clinical audits and national confidential enquiries at
the Clinical Governance and Risk Management Committee (CGRMC) to encourage staff
engagement, share the learning and ensure continuous quality improvement of all
our services.
The local clinical audits that CircleNottingham participated in during 2013/14 are
as follows:
Name of local clinical audit
Status
Percentage
of cases submitted
Dermatology
Status
Percentage
of cases submitted
Quickdash scoring – carpal tunnel
Completed
100%
Invasive Manchester-Oxford Foot Questionnaire Report
Completed
100%
Podiatric surgery invasive procedures
Completed
100%
Invasive Fixations Report
Completed
100%
Invasive Medications Report
Completed
100%
Invasive Anaesthetic Report
Completed
100%
Invasive post-treatment sequeliae
Completed
100%
Invasive PSQ10 response
Completed
100%
Post-operative care for hand patients
Completed
100%
Shoulder Audit
Completed
100%
Patient-related outcome post-carpal tunnel release using GROC and MYMOP scores
Completed
100%
Orthopaedics
Quality improvement of patient journey in dermatology outpatient clinic
In progress
100%
Endocrinology and rheumatology
Audit of biologic therapy use in psoriasis against NICE/BAD guidance
Completed
100%
BSR National Gout Audit
Completed
100%
Audit of biologic therapy use in psoriasis against NICE/BAD guidance – re-audit
Completed
100%
Thyroid management post-radioactive iodine
Completed
100%
Psoriasis – NICE guidelines
Completed
100%
Pituitary Apoplexy Audit
Completed
100%
Clear communication in GP letters regarding long-term prescriptions
Completed
100%
Vasculitis audit within BSR guidelines
In progress
100%
National Isotretinoin Audit
Completed
100%
Rheumatology Ultrasound Audit
In progress
100%
Psoriasis Assessment Audit
In progress
100%
Anti-TNF ankylosing spondylitis
Completed
100%
Mohs micrographic surgery – from a district general perspective
Completed
100%
Anti-TNF psoriatic arthritis
Completed
100%
Melanoma written information
Completed
100%
Anti-TNF rheumatoid arthritis
Completed
100%
Rheumatology Helpline Audit
Completed
100%
Cardiology, vascular and respiratory
95% one-stop appointment audit
Completed
100%
Gynaecology
Chronic obstructive pulmonary disease
Completed
100%
Colposcopy follow-up
Completed
100%
Outpatient coding
Completed
100%
Ovarian cancer
Completed
100%
A retrospective evaluation of the treatment options used to treat varicose veins
Completed
100%
Endometrial ablation as per NICE guidance
Completed
100%
Pain questionnaire outcomes EQ5D
Completed
100%
Bone density scanning – audit of acceptance criteria
Completed
100%
Letter turnaround time
Completed
100%
Completed
100%
CPAP Compliance Audit
Completed
100%
Effect of recently introduced HPV testing on workload in colposcopy and threshold
of intervention
Patients’ understanding of diagnosis
Completed
100%
The use of Esmya
Completed
100%
Uterine artery embolisation
Completed
100%
Did not attend audit
Completed
100%
World Health Organisation (WHO) surgical safety checklist compliance
Completed
100%
WHO surgical safety checklist cultural
Completed
100%
Wound infection, admission rates, pain and post-operative nausea rates occurring
in recovery, at 24 hours and at 28 days
Completed
100%
Recovery following wisdom tooth extraction
Completed
100%
Mystery shopper survey
Completed
100%
Patient satisfaction feedback cards
Completed
100%
Admission rates following day surgery and causes
Completed
100%
Radiology
Audit of completion of all radiology request cards
Completed
100%
Cannulation Audit
Completed
100%
Reporting turnaround for MRI and CT
Completed
100%
Cards v. e-requesting
Completed
100%
Review of orthopaedic letters
Completed
100%
Ionising Radiation (Medical Exposure) Regulations Criteria Audit
Completed
100%
Ultrasound FNA
Completed
100%
25
Day case
26
CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
Mandatory
statements
The reports of 96 local clinical audits were reviewed by the provider in 2013/14,
and CircleNottingham intends to take the following action to improve the quality
of healthcare provided:
Continued
Name of local clinical audit
Status
Percentage
of cases submitted
Association for Perioperative Practice (AfPP) regulatory audits
(health and safety, documentation checks, professional standards, infection control)
Completed
100%
Patient cancellation and ‘did not attend (DNA)’ audits
Completed
100%
Pre-operative assessments on day of surgical clinic
Completed
100%
QUAD
Completed
100%
RAD
Completed
100%
STOP
Completed
100%
Same-day admissions following day case surgery: a 24-month audit
Completed
100%
Functional recovery following laparoscopic day surgery – a seven-day follow-up study
Completed
100%
Chloraprep
Completed
100%
Laparoscopic
Completed
100%
Number of procedures performed by each operator
Completed
100%
Success of intubation of oesophagogastroduodenoscopy (OGD)
Completed
100%
Completion of OGD
Completed
100%
Colonoscopy completion rate
Completed
100%
Adenoma detection rate
Completed
100%
Sedation and analgesia for colonoscopy
Completed
100%
Quality of bowel preparation
Completed
100%
Repeat endoscopy for gastric ulcers within 12 weeks
Completed
100%
Colonic polyp recovery
Completed
100%
Correct identification of position of colonic tumours
Completed
100%
Patient survey
Completed
100%
Staff survey
Completed
100%
Patient comfort and anxiety scores
Completed
100%
Consent/safety checklist
Completed
100%
Waiting Times Audit
Completed
100%
Clinic waiting times
Completed
100%
Prostate cancer
Completed
100%
Oesophago-gastric cancer
Completed
100%
Patient survey – GMC questionnaire
Completed
100%
Referral quality
Completed
100%
GMC patient satisfaction
Completed
100%
IPT Audit
Completed
100%
Patient Medical Records Audit
Completed
100%
Total
96
Day case (continued)
Endoscopy
Digestive diseases
• Continue to proactively support all clinical units in the development of annual clinical
audit plans.
• Encourage participation and promote learning from all local clinical audits.
• Utilise the outcome of local clinical audits to build upon the quality of service provision
and improve the patient experience.
• Share the outcome of local clinical audits at the CGRMC to encourage staff engagement,
share the learning and ensure continuous quality improvement of all our services.
Many of our patients have a shared care pathway, moving between CircleNottingham and
Nottingham University Hospitals NHS Trust. Where the treatment centre only manages a
small part of a patient’s pathway, an agreement is in place that information will be utilised
from the shared healthcare record and included in the relevant shared audits.
In addition to participating in national clinical audits, national confidential enquiries and
local clinical audits, CircleNottingham also undertakes a facility-wide programme of audits
in relation to the following areas: health and safety, information governance, medical
records, infection prevention and control, hand hygiene, fire safety, medical gases,
controlled drugs and decontamination.
Participation in clinical research
CircleNottingham jointly hosts clinical research in conjunction with Nottingham
University Hospitals NHS Trust. The number of projects related to NHS services provided
by CircleNottingham in 2013/14, that were undertaken during that period, and that relate
to research approved by a Research Ethics Committee, was 21.
All research proposals undergo rigorous checks before clinical research can be undertaken
at CircleNottingham. Applications are made via the Local Research Ethics Committee
before approval is considered. The increasing level of agreement to support clinical research
demonstrates our commitment to improving the quality of care we offer and contributing
to wider health improvement.
Registration and external review
CircleNottingham is required to register with the Care Quality Commission (CQC), and its
current registration status is not compliant (compliance action requiring improvement).
27
28 CircleNottingham Quality Account 2013/14
Secondary Uses Service
CircleNottingham submitted records during 2013/14 to the
Secondary Uses Service for inclusion in the hospital episode
statistics which are included in the latest published data.
The percentage of records in the published data which included the patient’s
valid NHS number was:
For admitted patient care
100%
For outpatient care
100%
The percentage of records in the published data which included the patient’s
valid General Medical Practice Code was:
For admitted patient care
99.8%
For outpatient care
99.8%
CircleNottingham Quality Account 2013/14
The CQC has not taken enforcement action against CircleNottingham during 2013/14.
CircleNottingham has the following conditions on registration:
Site
Regulated activity
Nottingham NHS Treatment Centre • Treatment of disease,
Queen’s Medical Centre Campus
disorder or injury
Lister Road
• Diagnostic and
Nottingham
screening procedures
NG7 2FT
• Surgical procedures
• Family planning
• Termination of
pregnancies (of
pregnancy for patients
at no more than 14
weeks gestation within
the Nottingham NHS
Treatment Centre)
Conditions
Regulated activity must
not be undertaken on
persons under the age
of 14 years
CircleNottingham has been subject to one unannounced inspection by the CQC during
the reporting period, which occurred on 24th September 2013. The following standards
were reviewed:
•
•
•
•
•
Care and welfare of people who use services – achieved
Staffing – achieved
Supporting workers – action undertaken
Assessing and monitoring the quality of service provision – achieved
Records – action undertaken
Two areas for minor compliance action were identified where improvement was required;
action plans were developed immediately and have been implemented. The standards
where action was undertaken will be subject to the CQC inspection schedule. The final
report can be reviewed on the CQC website: www.cqc.org.uk.
Commissioning for Quality and
Innovation (CQUIN) payment framework
A proportion of CircleNottingham’s income in 2013/14 was conditional on achieving quality
improvement and innovation goals agreed between CircleNottingham and any person or
body they entered into a contract, agreement or arrangement with for the provision of NHS
services, through the CQUIN payment framework.
Mandatory
statements
Continued
29
30 CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
Part three
Patient, CircleNottingham
“Very friendly and made me feel safe
and at ease. The most friendly nurses
I have ever met.”
31
32
CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
Clinical unit
Quality Accounts
Achievement against quality improvement objectives 2013/14
Quality domain
Our quality priorities
for 2013/14
Outcomes
Status
Patient safety
Safer surgery – focuses on the
World Health Organisation
(WHO) surgical safety checklist
and team dynamics to prevent
never events
A dedicated skin surgery WHO surgical safety
checklist was designed by the clinicians and has
been implemented, forming part of the patient
pathway documentation
Achieved
Dermatology
About the clinical unit
The dermatology service is located in Gateways A (outpatient) and G (skin surgery) of
Nottingham NHS Treatment Centre. Although they are two distinct areas, they are viewed
as one clinical unit, working together as a unified team with a cohesive approach to ensure
that our patients experience compassionate care throughout their pathway. Our team
has embedded our credo into the heart of their service, consistently providing a first-class
service, and instilling confidence in patients when they are faced with acute and chronic
skin conditions.
Safer surgery audit undertaken monthly alongside
an observational audit to review practice
Continued high level of
dermatology training
Continue to deliver
research targets and
maintain CircleNottingham’s
reputation for meeting these
nationally, and continue to
maintain the comprehensive
local research network
(CLRN) research portfolio
We have an experienced and committed dermatology team that includes nationally
recognised consultants, clinical nurse specialists in skin cancer and chronic skin disease,
and 11 registered nurses and 11 healthcare assistants. The unit is supported by 11
administrators who meet and greet patients and co-ordinate the patient appointments
to ensure the smooth running of the unit.
Services provided
Tertiary level services for psoriasis, vulva disease and eczema, general dermatology
outpatient (including biologics), skin cancer target clinics, light therapy, day case treatments,
including a wide range of topical treatments, hand and foot PUVA, iontophoresis, skin
surgery and Mohs micrographicsurgery, wound checks, nurse-led biopsy service, leg
ulcer clinic, photo dynamic therapy, contact dermatitis and patch testing clinic, nurse-led
systemic therapy monitoring, nurse-led triamcinolone clinic, and BOTOX® treatment
for hyperhidrosis.
Consent practice in line
with national best practice
and evidenced
Activity (number of appointments)
2012
2013
% increase
Outpatient new
11,879
12,631
6.33
Outpatient follow-ups
35,440
37,162
4.86
Cancer referrals
5,995
6,417
7.04
Skin surgery
4,036
4,931
22.18
The CLRN research portfolio has been maintained,
and research supported by Circle has allowed
CircleNottingham’s dermatology services to
maintain fourth position for British Association
of Dermatologists Biologic Interventions
Register (BADBIR)
Achieved
BADBIR is a UK observational study which seeks to
assess the long-term safety of biologic treatments for
psoriasis. The National Institute for Health and Clinical
Excellence has recommended that all patients in the
UK receiving these new therapies for psoriasis should
be registered
Consent and Mental Capacity Act training delivered
to all relevant staff
Achieved
All staff have read and understood the consent policy
A monthly consent audit demonstrates improved
compliance with any occasional issue identified,
which is dealt with at the time of the audit
Challenges
During 2013, we saw a gradual increase of patients attending the dermatology service,
with a 22% increase in activity across all areas of the service. With the ever-increasing media
coverage and health promotion of skin cancer, the number of skin cancer referrals over the
last two years increased by 6% in one year alone. This increase in demand had a ‘knock-on’
effect; it was recognised that the staffing model did not meet the demands of the service.
Additional nursing staff were recruited and, in early 2014, the revised nursing establishment
was in place. In addition, recruitment of doctors within the unit had proven difficult due to a
national shortage of consultant dermatologists; however, we have continued to cope with
our increasing workload and are working extremely hard to attract the right people to join
our team.
All relevant staff have undertaken WHO safety training
Best patient
experience
Ensure clinic builds
(appointments slots) meet
current requirements and
optimise waiting times
A thorough analysis was undertaken to assess
previous activity, which then enabled us to plan
for future service demands
Achieved
Ensure pathway for on-call
patients is safe and appropriate
The process has been mapped, whereby the patient
Achieved
contacts their own GP with their skin concerns. The
GP then contacts the Nottingham University Hospitals
NHS Trust switchboard, who subsequently contacts the
on-call dermatology registrar
On-call slots were added to a number of the
locum clinics to ensure that they are available
daily, Monday to Friday
We have ensured that on-call appointment slots
are available every day during the working week
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34 CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
Clinical unit
Quality Accounts
Best clinical outcome
Continued
Same day biopsies
Dermatology
Quality domain
Our quality priorities
for 2013/14
Outcomes
Status
Most engaged staff
Improved communication
within the unit
We have introduced nurse, administration and team
leader meetings which are all held on a monthly basis
Achieved
31.2%
Dermatology
0.5%
Four partnership sessions have been undertaken
and covered the following:
• Patient Hour – quality quartet, patient
experience, feedback
• Datix and incident reporting
• Commissioning for Quality and Innovation
• Mental Capacity Act
• Skin surgery care pathway booklets
• Eighteen-week and cancer care pathway
• Presentations given by clinicians and clinical
nurse specialists around skin disease
Dermatology
–
0
82.7
Skin surgery
94.1
2.9%
Skin surgery
1.3%
Number of Stop the Line events
Quality review of 2013/14
Dermatology
Skin surgery
Patients with skin infection
Dermatology
Patients likely to recommend the service (net promoter score)
–
Incidents reported
The minutes and actions are available for the clinical
unit to view on the internal IT network
Best patient experience
Skin surgery
Most engaged staff
Skin surgery
0
Staff turnover
Dermatology
2.6%
Skin surgery
2.6%
Patients who responded to the Friends and Family Test
Average vacancies as percentage of headcount
Dermatology
Dermatology
16.9%
Skin surgery
48.4%
6.5%
Skin surgery
6.5%
Formal complaints and concerns
Mandatory training – direct hire
Dermatology
Dermatology
13
Skin surgery
0
68.8%
Skin surgery
68.8%
35
36 CircleNottingham Quality Account 2013/14
Clinical unit
Quality Accounts
Continued
CircleNottingham Quality Account 2013/14
Dermatology, outpatient and skin surgery have, throughout 2013/14, experienced a higher
than expected staff turnover and vacancy rate. This is, in part, due to the new contract which
started in July 2013 where staff previously provided under a secondment arrangement
either transferred to the service or found alternative employment. This, combined with the
increase in demand for the service, meant that a review of the establishment was required;
an increase in staffing levels meant that staff felt better supported and, in conjunction with
mandatory training and clinical supervision, there was an improvement in staff performance
as evidenced at appraisal.
Quality improvement priorities for 2014/15
Quality domain
Our quality priorities
for 2014/15
Success measures for 2014/15
Monitoring
and reporting
responsibilities
Best patient
experience
We have listened to our patients
and we will provide an efficient
checking-in and checking-out
process to reduce the amount
of time patients are waiting in
the unit
Patient feedback
Clinical
Governance and
Risk Management
Committee
(CGRMC)
Review of pathways for on-call
patients – this is to maintain the
process we introduced during
2013 and to ensure adherence
from new clinical members
of staff
Patient and staff feedback
Where clinically appropriate,
reduce unnecessary patient
visits to the treatment centre
Increase the number of telephone follow-up clinics
All patients will receive the
same high-quality care through
standardisation of the patient
pathway which is reflected in
the care pathway booklet
All patient care will be documented in the care
pathway booklet. This will be audited via our
documentation audit
Provide a sustainable chronic
disease management service
Understand the establishment for the service and
recruit as required
The clinical unit has a strong focus on monitoring quality and using it to make service
improvements. The clinical unit leadership team meet monthly to learn from incidents,
complaints, patient feedback, safety alerts, and NICE clinical guidelines. This information
is reviewed, understood and changed into positive action which is then shared with all the
team at the dedicated partnership sessions. There is a dedicated patient representative
working alongside the team to ensure that the needs of the patient and public are
considered and at the heart of decision-making.
The data shows that the team has a good incident reporting culture and all incidents are
investigated and mitigating action put in place. Patient feedback is actively sought with a
response rate of 16.9% and 48.4% respectively, combined with a high satisfaction rate of
82.7% and 94.1%. Where patients have raised concerns, the team has been proactive and
taken the opportunity to learn from them. Mirrors are now available to patients attending
for biopsies, so they can view the area for the procedure. For infection prevention, all
emollients are decanted into separate pots for each patient’s use. Staff are very alert to
mental capacity issues due to an incident that highlighted the need for further training.
Our mandatory training around mental capacity is over 90%.
Best clinical
outcome
Examples of improvements
2014 looks set to be an exciting time for the dermatology clinical unit, particularly with
the work being undertaken to introduce teledermatology. We have committed to support
our local commissioners in delivering against the joint commissioning objectives to reduce
avoidable attendance for patients to hospital.
Observational audit
Work with GPs to introduce teledermatology, so that
only confirmed skin cancer patients attend the hospital
CGRMC
Training and development for identified registered
nurses to complete the Nurse Prescribing Course
We are also ensuring that we provide a sustainable service and are succession planning
to develop a nurse consultant post and additional clinical nurse specialists in 2014.
Most engaged staff
Ensure all staff are aware of the
signs of dementia and ensure
that support is provided for
those in need. Where relevant,
work with other agencies to
provide support
Ninety per cent of relevant clinical staff to have
received training
Ensure that the monitoring
of quality is a prominent
component of the unit’s focus
Quality quartet shared with all staff at every
partnership session
Implementation of Circle
Operating System (COS)
across outpatients and
skin surgery
COS champions in place
Evidence of dementia screening tools in place
Evidence of referral to supportive services
Patient Hour discussed
Initiatives identified to improve services
Clear communication strategy of initiatives
to staff and patients
CGRMC
37
38 CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
Patient, CircleNottingham
Cardiology, respiratory and vascular
“Reception and
other staff were
very pleasant.”
About the clinical unit
The clinical unit is comprised of a number of different services which endeavour to
provide a high-quality service, ensuring that all our patients leave the treatment centre
with a clear understanding of their diagnosis and management plan. We pride ourselves
on our compassionate approach, and work hard to maintain a caring and skilled environment
in which patient safety and development of our staff are key focal points.
Although the activity within Gateway B is diverse in nature, the team works together
to create a cohesive unit. The team itself comprises long-standing physiologists and
clinicians, specialist nurses, registered nurses and healthcare assistants, all of who
are dedicated to delivering the values and behaviours of our credo.
Services provided
The following services are provided within the clinical unit:
• Cardiology – We are a European centre of excellence for the management
of hypertension.
• Respiratory – A general respiratory service, specialising in sleep and non-invasive ventilation.
• Vascular – We offer general vascular clinics specialising in the most modern treatments
for patients with varicose veins.
• Pain – Multidisciplinary pain service integrated with community care.
Challenge
We saw a total of 22,215 patients during 2013/14. This was just under 3,000 less than the
previous year and was a direct result of the cardiology service ceasing in July 2013. The tables
below show this in further detail:
Activity (appointments)
2012
2013
% comparison
Outpatient new
6,304
5,707
-9.47%
Outpatient follow-ups
18,873
16,518
-12.48%
The comparative numbers look very different when cardiology activity is removed:
Activity (appointments)
2012
2013
% comparison
Outpatient new
3,278
3,961
20.84%
Outpatient follow-ups
11,796
12,660
7.32%
The pain service was introduced to the treatment centre in September 2013, and we have
seen 500 patients during this time period. Since the service started six months ago, we
have experienced a significant increase in referrals, and the pain team has doubled in size
to match this growth; five new members of staff have been recruited.
Clinical unit
Quality Accounts
Continued
39
40 CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
Clinical unit
Quality Accounts
Continued
Achievement against quality improvement objectives 2013/14
Quality review of 2013/14
Quality domain
Our quality priorities
for 2013/14
Outcomes
Status
Best clinical
outcome –
patient safety
Co-ordination of home visits
for non-invasive ventilation
The commissioning of this service was ceased
Superseded
Ninety per cent of patients
will have clinical record
of diagnosis on the day
of treatment
Sixty-five per cent of the patients audited were
aware of their diagnosis and treatment plan
Partially met
Decrease waiting time
from referral to appointment
for patients
Audit to reduce 25% in average waiting times
Best patient
experience
Ensure waiting times are kept
to a minimum and any delays
are communicated effectively
to patients
Patients who responded to the Friends and Family Test
Formal complaints and concerns
Communication of any wait times was effectively
communicated to patients via the administration
staff and visually on the televisions located in the
waiting area
Attendance by at least six patients to three meetings
in the year
Joint approach towards patient
notes between nursing staff
and administration staff
Best clinical outcome
Administration and nursing staff now work as
a cohesive team in the process of patient notes
before, during, and at the end of each clinic
This has resulted in fewer issues, such as
missing documentation
Patients given a one-stop appointment
63.5%
Achieved
Number of incidents reported
0.8%
Terms of references and expectations of group written
All staff fully aware and supportive of patient
notes process and the tracking of them
13
Achieved
The support initially provided by the service has
enabled the user group to become independent
and now host their own meetings
Most engaged staff
16.6%
Not met
Audit was undertaken; however, the results did not
achieve a 25% reduction in the average waiting time.
This was due to the reduction of the cardiology
service, and we reduced the number of doctors
in the vascular service
Redesigned the clinic structure, increasing the
length of clinic time, and decreasing the amount
of clinic slots in the session
Patients likely to recommend the service (net promoter score)
80.8
The change process to improve the patient’s
awareness will form part of our 2014/15 priority
We review our patient feedback on a monthly
basis in order to address any peaks in waiting times
Run an effective patient lead
home ventilation support
group for respiratory patients
Best patient experience
Stop the Line events
Achieved
1
41
42 CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14 43
Clinical unit
Quality Accounts
Quality improvement priorities for 2014/15
Continued
Most engaged staff
Total sick days in month
Quality domain
Our quality priorities
for 2014/15
Success measures for 2014/15
Monitoring
and reporting
responsibilities
Best patient
experience
To provide respiratory patients
with a state-of-the-art overnight
sleep study service that is more
conducive to a restful experience
and, therefore, ensures
increasingly accurate results
Commencing in autumn 2014
Clinical
Governance and
Risk Management
Committee (CGRMC)
Set up a supervised
exercise programme
for vascular patients
Improvement of the patients’ walking distance before
and after programme
8.8
Staff turnover
1.0%
Vacancies as percentage of headcount
Best clinical
outcome
Mandatory training – direct hire
69%
Most engaged staff
We also actively promote the four Cs process (complaints, concerns, comments and
compliments) and see patient issues as an opportunity to learn. We have sought sleep
study equipment for a wider range of patients, based on a concern raised by a patient who
had an uncomfortable visit due to the straps on the continuous positive airway pressure
(CPAP) mask being too tight. We have an excellent safety culture where our staff are happy
to report when things have gone wrong, and have also been empowered to Stop the Line
when they perceive a risk to patients, staff or members of the public. This has happened
on one occasion when there were difficulties obtaining a medication required for a
procedure to take place.
Due to changes in the service, cessation of cardiology and the commencement of the
pain service, we were uncertain as to the required establishment; therefore, we decided
to delay recruitment until such time as we could define the requirements of the service.
The reduction of service meant that the average 7.2% headcount vacancy did not have
any effect on the safe provision of care.
Undertake a patient satisfaction survey
An improvement of quality of life change as per EQ5D
Percentage referred for angioplasty
7.2%
We actively seek feedback from our patients so that we can listen to their needs and change
our service to match their requirements. During this time period, 16.6% of our patients
provided feedback and, although the vast majority of our patients would be extremely likely
to recommend us, we have received lots of good advice about what we could do better.
We have enlisted the assistance of a patient representative who joins us in meetings and
provides us with a patient’s perspective on our quality data and proposed solutions.
Gradually increase activity to four patients per week
Provide a holistic pain service
with access to multidisciplinary
team (pain consultant,
extended scope practitioner
physiotherapist, pharmacist)
to support patients with a
debilitating condition
Quality of life measures
Participate in a thiazide
research project, which is aimed
at understanding the side effects
of this family of drugs (diuretics)
for hypertension
To recruit 15 patients to the research project
To refresh the Circle
Operating System (COS)
within the gateway, focusing
on new starters
COS champions identified
Ensure that the quality quartet
is more prominent in our
partnership sessions
CGRMC
Service evaluation
Results to be published in a journal in 2014/15
Output of working groups and initiatives
All staff to have a better understanding of
the quality quartet. Output of group workshops
and resulting initiatives
Mr Stephen Hyde, Patient and Public Engagement Group member
“As a patient representative, I found
the occasion a most useful way to
understand how the gateway works
with a strong spirit of continuous
improvement – the quality metrics
provided a clear base from which
to focus and move forward.”
CGRMC
44 CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
Patient, CircleNottingham
“Wasn’t kept waiting through my scan.
Lovely atmosphere that puts you at ease.”
Radiology
Clinical unit
Quality Accounts
About the clinical unit
Radiology services are situated in Gateway C at the Nottingham NHS Treatment Centre.
We aim to provide prompt access to diagnostic services, ensuring our patients receive
the best possible experience, that their privacy and dignity is maintained at all times,
and that their results are readily available in preparation for their future treatment.
Continued
The radiology service is delivered by qualified radiographers who undertake the diagnostic
imaging tests, and a number of specialist radiologists who approve the tests and report
the findings of the images. This gateway has three trained administration co-ordinators
who book the appointments for patients and ensure the smooth running of the unit. We
have two healthcare assistants who work alongside and support the radiographers and
radiologists to provide patients with information regarding the tests, provide physical
support for dressing/undressing, and act as a chaperone to ensure that privacy and
dignity is maintained.
During 2013/14, we have seen an increase in the number of diagnostic tests undertaken
from previous years. This has been due to the expansion of the irritable bowel service,
shoulder service, the introduction of the spine service, and the reintroduction of the pain
service at the treatment centre. Utilisation increased in January to almost optimal levels,
indicating that additional capacity is required.
Utilisation percentage for computerised tomography (CT)
and magnetic resonance imaging (MRI)
September 2013 to March 2014
120
100
80
60
40
20
0
CT
MRI
S
O
N
D
J
Services provided
MRI, x-rays, CT, ultrasound, and fluoroscopy for interventional cases.
F
M
45
46 CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
Clinical unit
Quality Accounts
Continued
Achievement against quality improvement objectives 2013/14
Quality domain
Our quality priorities
for 2013/14
Best patient
experience
Best clinical
outcome
Outcomes
Status
Quality domain
Our quality priorities
for 2013/14
Outcomes
Status
Provide separate waiting areas
Separate waiting areas have now been built within
for men and women, and ensure the unit, to ensure privacy for patients who
the unit complies with privacy
are required to wear a gown
and dignity requirements
Patient feedback has not highlighted any privacy
concerns since the work has been undertaken
Achieved
Most engaged staff
Employ a direct hire, full-time
radiology lead/manager to
oversee the operations of
the unit
A radiology manager was appointed from
September 2013; however, this requirement
has since been superseded
Achieved
The quality improvement priority will be carried
forward and incorporated into our 2014/15
programme of work
2014/15
programme
There are three full-time administration
staff members who are now fully trained
and competent
Achieved
Improve the amount of
information displayed around
the clinical unit on the history
of all the scans and what
patients can expect from their
treatment today, including a
patient pathway in pictures to
be displayed on the TV screens
Bring administration team
in-house
Bring radiography helpers
in-house
There are two full-time healthcare staff
members who are now fully trained
and competent
Achieved
Continue to reduce patient
waiting times – both for
pre-booked appointments
and walkaround appointments
The audit of arrival times and scan start times
demonstrated that:
• walkaround patients for plain film wait 10 minutes
• CT patients wait on average 35 minutes
• MRI* patients wait on average 75 minutes
• ultrasound patients wait on average 40 minutes
Achieved
Carry out an audit on the
accuracy of requesting
and reporting of x-rays for
orthopaedic patients, to
comply with the Ionising
Radiation (Medical Exposure)
Regulations (IRMER)
Accuracy of requesting against the IRMER
was undertaken as a recorded error log during
December 2013
Achieved
Best patient experience
• 1 x laterality issue
• 6 x three forms of identification not present
• 3 x clinical information missing
• 17 x illegible
• 6 x modality missing
• 21 x missing date
An efficiency project increased the number of MRI and
CT slots available in the working day to 15–18 patients
for MRI, and 24 for CT. However, the demand for MRI
increased at the same time and so utilisation remains
at 90%. Diagnostic imaging targets (DM01) have not
been breached throughout the year. Additional work
is required to provide additional capacity
*
Patients likely to recommend the service (net promoter score)
83
Patients who responded to the Friends and Family Test*
28.8%
Incidents reported against activity
Results are fed back to clinicians on the day of request
and also presented at the Clinical Governance and Risk
Management Committee
Increase patient capacity
by extending operational
working hours
Quality review of 2013/14
Achieved
It must be noted that MRI patients are asked to attend 30 minutes before their procedure
in case additional preparation is required.
0.01%
*
Excluding plain film. Plain film feedback is captured within the gateways.
47
48 CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14 49
Clinical unit
Quality Accounts
Continued
Best clinical outcome
Most engaged staff
Incidents reported against activity
Optimal value
Number of CT scans
0.5%
3,652
E-requests vs card
Number of MRI scans
51%
3,127
Stop the Line events
Number of plain film
0
10,070
Sickness days in year (five direct hire staff)
Number of ultrasound scans
4
4,402
DNA rate for CT
5.1%
DNA rate for MRI
6.9%
50 CircleNottingham Quality Account 2013/14
Clinical unit
Quality Accounts
Continued
The high net promoter score and low number of complaints and incident rates indicate
that patients appear to be satisfied with the service. Over 3,000 patients have provided
the service with useful feedback. On the whole, comments are very positive, stating that
the staff are polite, caring and compassionate. However, a number of patients did comment
on the length of time they were in the unit, perhaps not realising that there is a 20-minute
preparation time before many of the procedures, so they are required to attend before the
scan. This has been clarified in our appointment letters.
Although the incident rate is low, all staff are receptive to reporting incidents, including
the doctors. During this period, three incidents were reported in accordance with the Ionising
Radiation (Medical Exposure) Regulations, of which the following lessons were learned: • Equipment fault, resulting in a higher than intended dose. The investigation proved
inconclusive, but was discussed with the Health and Safety Executive and reported
to the Medicines and Healthcare Products Regulatory Agency.
• Unintended radiation dose given due to confusion in required modality; plain film
given instead of the required MRI scan.
• Unintended radiation dose given due to confusion in required modality; plain film
given instead of the required ultrasound.
The radiology clinical unit, in line with its priorities, recruited a number of direct hire staff
to support the clinical services acquired under a service level agreement with a neighbouring
organisation. The administration and healthcare assistant staff recruited provided the stability
the unit needed to ensure that patients received a smooth service and excellent experience.
Activity increased throughout the year, with over 21,000 procedures being undertaken.
The team worked hard to reduce the level of patients who ‘did not attend’ (DNA) their
appointment, by contacting patients prior to their appointment to remind them; however,
the rate for MRI averaged at 6.9% and 5.1% for CT, which is approximately 400 patients.
A reduction in DNAs will improve capacity issues and waiting times for diagnostic tests.
Quality improvement priorities for 2014/15
Quality domain
Our quality priorities
for 2013/14
Success measures
Monitoring
and reporting
responsibilities
Best patient
experience
Improve access to diagnostic
services by reduced waiting
times for diagnostic procedures,
in particular MRI and CT
Increase capacity to 18–20 scans for MRI per day
Performance Board
Maintain 80% utilisation to ensure urgent patients
can be given an appointment and scanned within
two weeks, and routine patients within four weeks
Reduce the number of ‘did not attends’ to below 3%
Monitor patients’ feedback and net promoter score
Best clinical
outcome
Do ‘no harm’ to our patients
Reduce the number of Ionising Radiation (Medical
Exposure) Regulations reportable incidents
by 50%
Clinical
Governance and
Risk Management
Committee (CGRMC)
Most engaged staff
Continue to support the service
with a sustainable workforce
and support business growth
Agree and monitor safe staffing levels to support
the service and ensure that future growth of business
is supported
CGRMC
Patient, CircleNottingham
“Made me feel at ease before and after
my operation. All nurses were very friendly.”
52
CircleNottingham Quality Account 2013/14
Clinical unit
Quality Accounts
Continued
CircleNottingham Quality Account 2013/14
Orthopaedics
About the clinical unit
The orthopaedic clinical unit is situated within Gateway D/E of the Nottingham NHS
Treatment Centre, and has seen approximately 29,000 patients throughout the year.
Orthopaedics is the medical specialty devoted to the diagnosis, treatment, rehabilitation
and prevention of injuries and diseases of the body’s musculoskeletal system. We strive
to support all patients with their individual needs, especially with regard to mobility issues,
which many of our patients have due to their condition. We have access to state-of-the-art
diagnostic services, specialist physiotherapists and occupational therapy, which helps us
provide a one-stop service to the majority of our patients. We also appreciate that a number
of our patients require access to healthcare later in the evenings and at weekends, so we
offer a wide range of evening and weekend appointments to give patients a variety
of choice.
In order to make way for an inpatient Short Stay Unit, the clinic rooms within Gateway D
have been converted into a ward area. This has meant that the orthopaedic consultants
now share the clinic space with Gateway E (endocrinology and rheumatology). This
has meant a redesign of the shape of the working week for both teams. The consultants
tried various clinic models until they reached a solution that met everyone’s needs.
We have also been able to share resources allowing for better utilisation of the existing
administration and nursing staff.
Achievement against quality improvement objectives 2013/14
Quality domain
Our quality priorities
for 2013/14
Outcomes
Status
Best clinical
outcome
All preoperative assessments
for hand patients are undertaken
in this building to ensure a onestop pathway
The designated hand specialist practitioner is
in place and supports the one-stop hand service
Achieved
Acute musculoskeletal service
to commence in the gateway;
provide GPs with fast access
to a consultant
This service has been successfully up and running for
one year within Gateway D, with a two to three-day
turnaround for GP referrals being received. Please
note that this service is not on Choose and Book
Achieved
Extended preoperative
assessment availability
All shoulder and elbow patients are now assessed
preoperatively in the unit on the day of their
outpatient appointment
Achieved
Preoperative assessment is
held in the gateway supported
by trained staff and competent
venipuncture and recording
of ECGs
Three staff nurses are fully trained in all aspects
of preoperative assessment
Achieved
Develop a pathway that reduces
the time patients wait for MRI,
CT, and ultrasound, and return
to clinics for their results
Two staff nurses trained in IRMER principles
to enable quicker access to diagnostic tests
Achieved
Nursing staff to become
competent at applying
plaster casts for patients
The training for staff is scheduled to begin
in July 2014 due to trainer availability
2014/15
programme
Administration and
nursing staff understand
each other’s roles in the
patient’s journey
The majority of our staff have shadowed each
other’s roles, and this also forms part of the
new starter programme
Achieved
Nursing staff to complete
competency framework that
allows them to individually
care for patients post hand
surgery, following guidelines
and protocols, reducing the
need to see medical staff
All nursing staff have a tailored competency
pack which is reviewed and updated during
their appraisal process
Achieved
Best patient
experience
This year, we have redesigned our physiotherapy service and are now seeing three times
more patients. We have also worked collaboratively with our consultants to ensure that we
are delivering services in an increasingly integrated way, which has enabled greater access to
appointments for patients. We have experienced challenges in recruiting and maintaining staff
competencies around the plaster service; however, we have been actively seeking innovative
ways of delivering the service.
Services provided
Foot and ankle, podiatry, hand and wrist, shoulder and elbow, hip and knee, and hip
revision outpatient service. The gateway also offers physiotherapy, a nurse specialist
service, soft tissue disorders, occupational therapy and acute pain service.
Most engaged staff
The patient pathway has been streamlined so that
the pathway is less fragmented and patients move
directly from arrival to diagnostics to clinician, rather
than clinician to diagnostics and back to clinician
53
54 CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
Clinical unit
Quality Accounts
Continued
Quality review of 2013/14
Best patient experience
Best clinical outcome
Patients likely to recommend the service (net promoter score)
Most engaged staff
Staff turnover
81.6
1.2%
Patients who responded to the Friends and Family Test
Vacancies as percentage of headcount
21.7%
4.6%
Formal complaints and concerns
Mandatory training – direct hire
8
86.8%
Incidents reported against activity
Safeguarding training
0.40%
96.7%
We have listened to our patients via their feedback, with 21.7% of patients providing
feedback during 2013/14. Although most of our patients are extremely satisfied with
the service, we specifically ask: “What we could have done better?”, in order to continuously
improve, and we also address concerns raised directly via the complaints process. The
overriding message received is that patients feel they spend a long time in the unit and
move from one specialist to another. Although this means that they can get their tests,
diagnosis and treatment plan in one visit, there is a desire from our patients to make the
pathway smoother.
Staffing within the unit remained stable throughout 2013/14, with low staff turnover
and a minimal vacancy headcount. We undertook a review of the workforce during this
period, which highlighted unnecessary posts in the establishment following the merge of
Gateway D and E. These posts were removed via natural wastage; however, the headcount
percentage was not amended to reflect this change and, therefore, the 4.6% vacancy did
not affect the safe staffing levels required to run the service. Having a stable workforce
has enabled us to retain a high mandatory training rate, especially for safeguarding, which
we see as important to the service.
55
56
CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
Clinical unit
Quality Accounts
Continued
Quality improvement priorities for 2014/15
Quality domain
Our quality priorities
for 2013/14
Success measures
Monitoring
and reporting
responsibilities
Best patient
experience
Reduce the length of time
patients are kept in the unit,
but still retain the one-stop
service
Reduction in length of time in the unit
Clinical
Governance and
Risk Management
Committee (CGRMC)
Multidisciplinary approach retained but delivered
to patient by one individual (multi-skilling staff)
Increase in new activity
Patient satisfaction
Best clinical
outcome
Most engaged staff
Introduction of patient
experience champions to
advocate the voice of the
patient, review feedback
and develop initiatives to
make change
Champions in place
Improve clinical outcomes
by providing nerve conduction
studies
Reduce the waiting time for patients requiring
nerve conduction studies, including reporting times
Better understand the clinical
outcomes for shoulder patients,
so that care can be tailored to
improve clinical recovery times,
allowing patients to return to
their normal activity quickly
and their quality of life (QOL)
is improved
Clinical outcome scores – Oxford shoulder
and elbow score
Engage and empower our staff
to contribute to the national
‘paper light’ agenda, which
will reduce the burden on the
environment and ensure that
patient information is electronic
and accessible for those caring
for the patient
Reduction in obtaining records, therefore, reducing
the burden on records staff
Feedback reviewed and shared with all staff at
partnership sessions
List of initiatives with clear outcomes to be developed,
implemented and outcomes shared at the CGRMC
CGRMC
QOL scores
Leadership 40
Use of tablets to capture patient feedback, local
audits, clinical outcomes and mobile meetings
Patient, CircleNottingham
“Physiotherapist was very helpful and clearly
explained method of treatment. Excellent!”
57
58 CircleNottingham Quality Account 2013/14
Clinical unit
Quality Accounts
Continued
CircleNottingham Quality Account 2013/14
Endocrinology and rheumatology
About the clinical unit
The endocrinology and rheumatology clinical unit can be found in Gateway E. The unit team
aims to provide all patients with a service that maintains their privacy and dignity, and cares
for them as individuals. Rheumatology is a clinical specialty dedicated to the care of patients
with arthritis and related disorders, and endocrinology is the specialty treating patients with
diseases affecting the endocrine glands of the body.
Quality domain
Our quality priorities
for 2013/14
Outcomes
Status
Best patient
experience
(continued)
Provide the patients having
therapy for osteoporosis
with a one-stop service
in the treatment centre
There is a process for which patients can have a DEXA
scan and an outpatient appointment on the same day.
Where this cannot be achieved, patients are offered
an alternative appointment
Achieved
New to appropriate
follow-up ratios
Rheumatology
The rheumatology service is delivered by eight consultants and six nurse specialists,
who provide additional education, support and monitoring of treatment for patients.
The consultants have individual areas of expertise, which include rheumatoid disease,
connective tissue disorders (lupus, scleroderma myositis), ankylosing spondylitis, psoriatic
arthritis, reactive arthritis, vasculitis, polymyalgia rheumatica, crystal arthritis, osteoporosis,
osteoarthritis, fibromyalgia, regional soft tissue, and rheumatic disorders. The specialty is
supported by diagnostic facilities, including detailed blood tests and imaging. Due to the
chronic nature of the diseases, many of our patients are long-term patients. Therefore,
we have established a follow-up regime that meets the clinical needs of the patient; this is
reactive so that when patients are stable, they have minimal contact. But when the disease
flares, they have access to a helpline where nurse specialists provide advice and support.
If a patient requires a consultation, the nurse specialists can make an appointment for
the patient over the phone.
Endocrinology
The service is provided by a dedicated team of seven consultants and two nurse specialists,
who provide a range of services such as assessment of secondary causes of hypertension,
osteoporosis and other metabolic bone disorders, thyroid nodule clinic, transition clinics
for patients with Turner syndrome and for patients moving from paediatric to adult services
who have endocrine disorders, and hormonal management of gender reassignment. We
provide education and support to patients with adrenal insufficiency in the form of a
patient support group, and we have developed a range of patient-friendly information
leaflets covering a range of endocrine disorders. We support colleagues in primary care
who request written advice and guidance using the Choose and Book appointment system.
Achievement against quality improvement objectives 2013/14
Quality domain
Our quality priorities
for 2013/14
Outcomes
Status
Best patient
experience
Community clinics
The commissioners did not want this to progress
any further
Superseded
(a) Identify subgroups of
patients who can be
managed safely and
effectively close to
their own home
(b) Establish the community
clinic, and resource this
appropriately according
to patient needs
(c) Assess patient satisfaction
with the delivery of
community clinics
Best clinical
outcome
(a) The new to follow-up ratio for rheumatology
is consistently greater than the national upper
quartile ratio of 2.89; however, this is under
(a) Establish appropriate new
review on a consultant by consultant basis.
to follow-up ratios according
The endocrinology new to follow-up ratio
to case-mix, to ensure new
fluctuates around the national upper quartile
patients can be seen promptly
ratio of 1.64 and is monitored on a monthly
(approximately 4:1)
basis by the clinical unit leads
(b) Follow-up patients
(b) To ensure compliance with NICE guidance,
appropriately according
all rheumatology patients are given an annual
to national guidance and
follow-up appointment
clinical need
(c) Those rheumatology and endocrinology patients
(c) Establish pathways to
who can be managed outside of a routine clinical
identify patients who can
regime are done so, either by the nurse specialist
be managed for follow-up
or their GP
in primary care or reviewed
in nurse clinics and by
telephone consultation
Achieved
Patients will be involved in
a cycle of feedback on their
appointment, understanding
of treatment options, and
clinic letter
The 28-day questionnaire was undertaken once
in this period, with the results shared at the local
clinical unit meeting
Achieved
Multisystem disease
management
There is a combined interstitial lung disease and
rheumatology clinic, along with a dermatology
and rheumatology clinic
Achieved
(a) Create dedicated clinic for
patients with multi-system
disease staffed by specialist
consultants (PCL/PC3)
(b) Improve access to
other specialists with
improved interdisciplinary
management and access
to other specialists
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60 CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
Clinical unit
Quality Accounts
Quality review of 2013/14
Continued
Best patient experience
Quality domain
Our quality priorities
for 2013/14
Outcomes
Status
Best clinical
outcome
(continued)
Ultrasound
(a) Provide ultrasound
assessments for patients
to objectively demonstrate
successful treatment
to target in rheumatoid
arthritis and achievement
of remission
(b) Provide ultrasound-guided
injections as clinically
indicated
(c) Assess patient satisfaction
with delivery of ultrasound
assessments and guided
procedures
(d) Contribute to additional
teaching and training
programme in ultrasound
nationally
All rheumatologists have access to a portable
ultrasound machine during outpatient clinics; this
allows them to offer ultrasound-guided injections
on the day of the outpatient appointment. There is
also a dedicated ultrasound clinic for those patients
who require a more detailed investigation
Achieved
Staff will be trained to undertake
venipuncture to support the
out-of-hours clinics
The clinical staff are trained in venipuncture and
are available to support every clinic, which means
that no patients have to return for such tests
Achieved
Staff are to be supported with
training that extends their roles,
giving them more satisfaction
in their role
All staff have been given a professional development
plan as part of their performance review. Some have
chosen to expand on their current knowledge, and
other have chosen to explore new avenues
Achieved
Multi-skilling of nursing and
administration staff to provide
in-depth knowledge of patient
pathways. This will allow mutual
understanding of each other’s
roles
The majority of our staff have shadowed each
other’s roles, and this also forms part of the new
starter programme
Achieved
Research
(a) Establish CircleNottingham
in the top five recruiting
centres in the UK for
arthritis research
(b) Aim to offer the majority of
patients the option to take
part in research as part of
their standard of care
(c) Extend high-quality research
portfolios in the fields of
rheumatoid arthritis,
osteoporosis, connective
tissue disease and vasculitis,
with research grants and
increased recruitment
CircleNottingham is now a top five recruiting centre
in the UK for arthritis research
Most engaged staff
Patients likely to recommend the service (net promoter score)
83.8
Patients who responded to the Friends and Family Test
22.5%
All patients who attend the rheumatology service
are invited to complete a patient feedback card,
with the results discussed monthly at the clinical
unit meeting, and learning opportunities acted upon
Formal complaints and concerns
5
Best clinical outcome
All patients are requested to participate in research;
patient information is given; additional information is
displayed on the television screens; and flexible access
to clinics, particularly in the evening, is provided
We have extended our research portfolio year on year,
and we are currently undertaking four research projects
Incidents reported against activity
0.77%
Stop the Line events
0
61
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CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14 63
Clinical unit
Quality Accounts
Quality improvement priorities for 2014/15
Continued
Most engaged staff
Average sick days in month
Quality domain
Our quality priorities
for 2013/14
Success measures
Monitoring
and reporting
responsibilities
Best patient
experience
Introduction of patient
experience champions to
advocate the voice of the
patient, review feedback
and develop initiatives
to make change
Champions in place
CGRMC
Reduce unnecessary
visits to hospital
Increase telephone follow-ups
Introduction of rheumatology
day case which will provide
intravenous infusions for
patients with active disease,
ensuring the whole service is
delivered by the same team
Service introduction in July 2014
Introduction of endocrinology
testing ensuring the whole
service is delivered by the
same team
Service introduction between July and September 2014
Engage and empower our staff
to contribute to the national
‘paper light’ agenda, which
will reduce the burden on the
environment and ensure that
patient information is electronic
and accessible for those caring
for the patient
Reduction in obtaining records, therefore, reducing
the burden on records staff
4
Staff turnover
0.5%
Vacancies as percentage of headcount
Best clinical
outcome
4.6%
Mandatory training – direct hire
80%
We have listened to our patients via their feedback, with 22.5% of patients providing
feedback during 2013/14. Although most of our patients are extremely satisfied with the
service, we specifically ask: “What could we have done better”?, in order to continuously
improve and take concerns raised via the complaints process. The overriding message
received is that patients feel they would benefit from a smoother pathway between the
gateway, pharmacy and phlebotomy. As such, a review of the opening hours and processes
for both services has been undertaken, with a view to extending the opening hours for each
of these services. It was also suggested that the waiting room facilities were enhanced to
accommodate longer waiting times.
Staffing within the unit remained stable throughout 2013/14, with low staff turnover and a
minimal vacancy headcount. We undertook a review of the workforce during this period,
which highlighted unnecessary posts in the establishment following the merge of Gateway
D and E. These posts were removed via natural wastage; however, the headcount percentage
was not amended to reflect this change and, therefore, the 4.6% vacancy did not affect the
safe staffing levels required to run the service. Having a stable workforce has enabled us to
retain a high mandatory training rate, especially for safeguarding, which we see as important
to the service.
Most engaged staff
Feedback reviewed and shared with all staff
at partnership sessions
List of initiatives with clear outcomes to
be developed, implemented and outcomes
shared at the Clinical Governance and Risk
Management Committee (CGRMC)
More nurse-led services
CGRMC
Service review audit
Service review audit
Use of tablets to capture patient feedback, local
audits, clinical outcomes and mobile meetings
CGRMC
64 CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
Patient, CircleNottingham
Gynaecology
“Very friendly and helpful, making
me feel at ease. Great team you
have…everybody smiled and made
me feel so relaxed.”
About the clinical unit
The gynaecology service is located in Gateway F of the Nottingham NHS Treatment
Centre, where we saw approximately 18,000 patients during 2013/14. The clinical care
provided is consultant-led and supported by a team of experienced nurses and healthcare
assistants; an excellent administrative team facilitate our clinic appointments. We promote
a ‘one-stop’ service where patients are provided with diagnostic tests and clinical review,
to ensure that they receive diagnosis and a treatment plan at their first appointment. We
also offer some appointments in the community setting. This means that patients can see
a specialist closer to home, which we have found eases access to our service. We are proud
to be a teaching unit, we support general practitioner training and both medical and nursing
students, as well as junior doctors wishing to specialise in the area of women’s health.
During 2013/14, we worked alongside our equipment sterilisation contractor, undertaking
a service improvement project which has resulted in a reduction in the number of cancelled
appointments due to unavailable equipment. We also saw a shift in commissioned services,
with the smear service moving away from acute providers, and the direction of travel for
this service better placed in community services. This reduced activity within the service;
however, changes to human papilloma virus (HPV) testing has increased the activity within
our colposcopy service. We have introduced hysteroscopic morcellation (removal of uterine
polyp) in an outpatient setting, which has reduced the number of patients requiring a day
case procedure. This increases the recovery time of the patient and enables them to be
discharged home sooner. Patients are then able to resume normal activities quicker as
they have not had a general anaesthetic.
Services provided
Gynaecology includes general and suspected cancer outpatient clinics, menopause clinic,
vulval skin disorder clinic, and a range of services including continence investigations
and advice, unplanned pregnancy assessment, sterilisation and DEXA (bone mineral
densitometry) scanning. Our menstrual disorders include a one-stop hysteroscopy
service, endometrial ablation and a uterine fibroid clinic.
Colposcopy and hysteroscopy services are also provided.
Clinical unit
Quality Accounts
Continued
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66 CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
Clinical unit
Quality Accounts
Continued
Achievement against quality improvement objectives 2013/14
Quality review of 2013/14
Quality domain
Our quality priorities
for 2013/14
Outcomes
Status
Patient safety
We will participate
in a colposcopy quality
assurance peer review
The schedule for review was postponed from 2013
until 2014
Superseded
We will reduce negative
comments relating to waiting
times in the clinical unit
Although we have seen a similar number of comments
regarding waiting times, we have, however, seen an
increase in the number of positive comments
We will reduce unnecessary
hospital attendance and
support care closer to home
by commencing a pilot of
gynaecology clinics being held
within a community setting
We have established gynaecology clinics in Borrowash Achieved
and Peartree in Derbyshire, and also clinics in Mansfield
and Southwell. The community clinic Friends and Family
Tests have shown a high satisfaction rate, consistently
achieving 100%
We will establish a Staff Focus
Group aimed at improving the
overall service provision
We have developed a staff focus group which
meets on a regular basis, looking at patient feedback
comments and acting on any trends. An example was:
patients telling us that the television screens were not
being updated. The team swarmed and developed a
more robust process, whereby the nursing staff inform
the administration team when a delay of more than
15 minutes has occurred and, therefore, the screens
are updated
Achieved
We will establish a rapid cycle
staff survey and learn from
the feedback
We will increase staff satisfaction throughout
the year and demonstrate this via re-audit
Partially achieved
We will develop a Healthcare
Assistant (HCA) Training
Programme
Competency pack has been developed for all HCAs
We will have a sustainable,
dedicated and knowledgeable
workforce within the
clinical unit
Some HCAs still need to attend training
Best patient
experience
Clinical
effectiveness
We will achieve positive feedback following the
peer review and develop an action plan to address
any outstanding actions
Patients likely to recommend the service (net promoter score)
2014/15
programme
83.2
Partially achieved
Patients who responded to the Friends and Family Test
28.7%
Formal complaints and concerns
8
Best clinical outcome
Incidents reported against activity
0.73%
Stop the Line events
1
We have incorporated the national staff net promoter
score into our appraisal process which was undertaken
in March 2014. We are currently reviewing the findings
and will be developing work streams to support our staff
HCA training is in place via a clinical skills trainer
Best patient experience
Partially achieved
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CircleBath Quality Account 2013/14 69
Clinical unit
Quality Accounts
Quality improvement priorities for 2014/15
Continued
Most engaged staff
Staff turnover
Quality domain
Our quality priorities
for 2013/14
Success measures
Monitoring
and reporting
responsibilities
Best patient
experience
Introduction of patient
experience champions to
advocate the voice of the
patient, review feedback
and develop initiatives
to make change
Champions in place
CGRMC
Reduce the length of time
patients are kept in the
unit, but still retain the
one-stop service
Reduction in length of time in the unit
We will participate in
a colposcopy quality
assurance peer review
Planned for July 2014
Reduce the number
of unnecessary visits
to hospital
Ensure that new to follow-up ratio is in line with
national best practice
1.2%
Vacancies as percentage of headcount
2.3%
Mandatory training – direct hire
Best clinical
outcome
63.8%
We have a very high patient feedback response rate and have exceeded the agreed
internal target of 20%. We also have a high net promoter score, indicating that our patients
are satisfied with the service and would be likely to recommend us. The feedback received is
very complimentary to the staff, with a high proportion of patients stating that our staff are
very caring and welcoming. Although we have worked very hard to reduce our waiting times,
this is still a recurring theme when we ask what could we have done better; however, we
have noticed that we are receiving more positive comments around this topic. We feel that
this is due to better communication of waiting times to our patients and regularly updating
the television screens.
Feedback reviewed and shared with all staff at
partnership sessions
List of initiatives with clear outcomes to be developed,
implemented, and outcomes shared at the Clinical
Governance and Risk Management Committee (CGRMC)
Patient satisfaction
CGRMC
We will achieve positive feedback following the
peer review, and develop an action plan to address
any outstanding actions
Work with commissioners to develop a triage
criteria for GPs to use
Telephone advice for GPs
Introduction of telephone follow-ups
Achieve KC65 targets
Routinely monitor and achieve KC65 targets
The KC65 forms part of the
wider NHS Cancer Information
Strategy, which aims to improve
the effectiveness and efficiency
of care delivery. The information
is used to reduce the incidence
of invasive cervical cancer, and
to monitor the performance
of colposcopy clinics on local,
regional and national levels
During our partnership sessions, we advocated the requirement to report when things
go wrong, and have empowered our staff to ‘Stop the Line’ when they perceive a risk to
patients and staff. This has resulted in one Stop the Line event, which generated learning
that was relevant to the whole treatment centre around patients with learning disabilities.
This has led the organisation to provide awareness sessions for all staff in how
to support learning disability patients and their carers.
Most engaged staff
Engage and empower our staff
To develop a number of initiatives that will reduce
to contribute to the national
the dependency on paper
‘paper light’ agenda, which
Introduction of text reminder service for appointments
will reduce the burden on the
environment and ensure that
patient information is electronic
and accessible for those caring
for the patient
Develop and invest in our
staff skills and competencies
Add to and further develop the generic competency
package for nursing staff and healthcare assistants,
by including dedicated gynaecology competencies
CGRMC
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CircleNottingham Quality Account 2013/14
Patient, CircleNottingham
Day case
“I came in as a day
case in July and,
from beginning to
end, the staff were
all welcoming and
very helpful and
informative.”
About the Clinical unit
Clinical unit
Quality Accounts
The day case unit is very much the heart of the Nottingham NHS Treatment Centre, where
we undertook 10,494 day case procedures during 2013/14. Our ward area is used for first
and second stage recovery, allowing patients to be treated with privacy, dignity and respect
by nursing staff who are passionate about day case surgery. We have five fully-equipped
theatres with six first stage recovery bays and 26 second stage bays, all configured to
provide the utmost privacy and dignity for our patients, and ensuring that compliance
around eliminating mixed-sex accommodation is adhered to. The unit is staffed with
55 clinical staff, consisting of both registered and unregistered personnel.
Continued
Our expertise has been utilised to provide support and advice to the project team
who commissioned the building and opening of an 11-bed Short Stay Unit. The unit
was developed to provide care for those patients who require additional recovery time.
An extensive ‘Ready for Operations’ (RFO) programme alongside our commissioners and
the Care Quality Commission (CQC) was undertaken before the unit opened. The purpose
of the RFO was to test patient pathways, to and from theatre, and ensure that our policies
and procedures were fit for purpose and that our patients would be cared for in a safe
environment. The unit opened in April 2014.
Services provided
General surgery, gynaecology, chronic pain treatments, orthopaedics (foot and ankle,
hand, lower limb, shoulder surgery), urology, podiatry, and venesection services.
Achievement against quality improvement objectives 2013/14
Quality domain
Our quality priorities
for 2013/14
Outcomes
Status
Best clinical
outcome
(patient safety)
World Health Organisation
(WHO) surgical safety checklist
compliance at stages 2 and 3
Monthly audits – aim for 95% overall compliance
at all stages of the WHO surgical safety checklist.
Currently, we achieve 95% stage one, 93% stage
two and 81% stage three
Partially achieved
Continued ability to ‘Stop the
Line’ if safety concerns arise
Patient recommendation and
net promoter scores (NPS)
An observational audit was implemented to ensure
that all participate in the WHO surgical safety checklist
and observe behaviours expected of our staff
We aspired to obtain 100% of our patients that
would recommend, and a NPS of 85
Partially achieved
99.3% of our patients said they would recommend
us, and we achieved a NPS of 84
Best patient
experience
Improve patients,
consultants, anaesthetist
and staff experience
We have developed a pre- and post-theatre briefing
pro forma which will be adopted in 2014/15. The
results will be fed through to the clinical leadership
team and patient champion forum
Achieved
Introduce a dignity passport
into care pathway, reducing
incidents/comments relating
to social issues
This project was put on hold while we
concentrated on improving our staffing levels
2014/15
programme
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CircleNottingham Quality Account 2013/14
Clinical unit
Quality Accounts
Continued
Achievement against quality improvement objectives 2013/14
Quality review of 2013/14
Quality domain
Our quality priorities
for 2013/14
Outcomes
Status
Best patient
experience
(continued)
Introduce inpatient beds
to enable improved postoperative care
Identification of a suitable space for inpatient beds
was agreed and signed off by the Executive Board,
along with associated budget for the build
Achieved
Best patient experience
Patients likely to recommend the service (net promoter score)
83.6
Build was commissioned and completed by January 2014
Patients who responded to the Friends and Family Test
‘Ready for Operations’ was carried out from January to
March 2014 and approved by commissioners and the
Care Quality Commission
54.6%
Beds were opened to patients in April 2014
Most engaged staff
Improve communication
methods to patients
Develop a video presentation about the unit,
with availability on the internet
Achieved
Improve all aspects of
the patient’s pathway
Further improve a patient’s experience by use of the
mystery shopper feedback, and results discussed
at patient champion monthly meetings
Achieved
Scenario training and learning
from incidents through practical
re-enactment
We have an excellent reporting culture, with an
incident reporting rate of over 3% (against activity)
Achieved
Support of incident reporting
by staff
Maintain staff working
conditions, ensuring
timekeeping, breaks
and work-life balance
is maintained
9
Best clinical outcome
We have undertaken four practical scenario training
sessions, including rapid access to blood product and
cardiac arrest
All staff have an identified line manager to support
them through the appraisal process, monitor sickness,
and annual leave booking process
Formal complaints and concerns
Achieved
Line managers are able to identify staff who may
require additional support within the unit, and
may review activities undertaken by an individual
to ensure they are able to continue at work
Learning from clinical audits
The learning that has been implemented as a result of the clinical audits undertaken
within the clinical unit is as follows:
• Increased safety awareness with the World Health Organisation (WHO) surgical safety
checklist observational audit.
• Clinical recovery audits (including 24-hour and 28-day) resulted in patient information
updates for discharge leaflets, hernia and vascular leaflets for example.
• Association for Perioperative Practice audits continue to demonstrate high clinical
and professional standards on the unit.
• British Association of Day Surgery audits to review a 24-hour contact service for the
patients; patients are now offered a choice of a telephone call or use of the answerphone
service which has documented retrieval three times a day.
Preoperative assessments done on same day
54.9%
Unplanned transfers
0.44%
Incidents reported against activity
3%
Patients asked in audit ‘satisfied’ with analgesia
97.7%
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Clinical unit
Quality Accounts
Continued
Best clinical outcome
(continued)
Same-day cancellations
3.5%
Stop the Line events
13
Patients having a venous thromboembolism risk assessment
95%
Most engaged staff
Staff turnover
1.9%
Vacancies as percentage of headcount
11.7%
Mandatory training – direct hire
71.3%
The Commissioning for Quality and Innovation now requires day case units to achieve a
30% response rate to the Friends and Family Test for 2014/15. We have already started
collecting this data and have exceeded this target in 2013/14 by obtaining 54.6% feedback
from our patients. In order to sustain this level of participation, we have assisted in the
development of an e-capture tool to collect feedback directly from the patients, which
also provides us with instant access to the views of our patients, making our process truly
real time. Our patient champion meetings continue to happen regularly, with a member
of the Patient and Public Engagement (PPE) Group attending. We have found their input
invaluable and aim to continue building on this partnership. This year, we have developed,
in collaboration with the PPE Group, an information presentation describing the patient’s
journey through the Day Case Unit. This is shared with our patients while they wait for
their pre-assessment.
We are pleased to see a reduction in the number of formal complaints and concerns. We
believe this is as a result of our hourly rounding process where nurses see the patients at
specific time intervals. This allows our staff to anticipate patients’ needs and provide regular
interaction so that patients can ask questions and, where necessary, resolve issues as and
when they arise. We have an excellent reporting culture, and staff are empowered to Stop
the Line when they feel that patients, members of staff or the public are perceived to be at
risk of harm. Staff have reported 13 Stop the Line events of which we have learnt valuable
lessons such as:
• Wrong site block – causal factors, unclear allocation of staff to assist anaesthetist, Stop
Before you Block was not transparent, the (WHO) surgical safety checklist not designed
to accommodate block patients. Following the incident, we allocated dedicated staff to
support the anaesthetists when performing the blocks, ‘Stop Before you Block’ signage at
present on the imaging equipment, and changes were made to the WHO surgical safety
checklist to have sign-off pre block.
• Multiple changes to operating list due to clinical requirement, causing confusion to
staff. Operating list stopped, case mix and patient selection reviewed, consultant
approved changes made, new lists typed and operating list updated. The process
for listing patients was reviewed with the lead clinician and the new process agreed.
During 2013/14, we experienced staffing challenges along with other healthcare providers.
At this time, we had a vacancy headcount of around 11%. Nursing recruitment proved
difficult as there was a national shortage of qualified and experienced theatres nurses,
operating department practitioners and recovery nurses. However, safe staffing levels
were maintained throughout this challenging time, as activity was flexed up and down to
match. In September 2013, the CQC inspected us against the standards for quality and safety,
concentrating specifically on safe staffing levels. We were found to be compliant with this
standard. We have increased the use of recruitment agencies and undertake recruitment
events. We have also employed long-term temporary agency staff to help support the
clinical areas.
We held five partnership sessions during 2013/14, providing the team with an opportunity
to understand our goals for the forthcoming year and ensure we all remained focused on
providing high-quality care for our patients. In February, we took the team to Twycross Zoo,
where they were met by an inspirational speaker, Darryl Woodman, from The Art of Being
Brilliant, who gave a motivational positive session for the staff. The purpose of the session
was to get minds and spirits aligned to being a high performing, cohesive and productive
team after a year of challenges. Staff have fed back and advised the Clinical Governance and
Risk Management Committee how the session made them feel more empowered, both
professionally and personally, to maintain a positive nature. A motivational noticeboard
has been set up, and staff review activities within the unit which can be displayed.
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CircleNottingham Quality Account 2013/14
Clinical unit
Quality Accounts
Continued
Quality improvement priorities for 2014/15
Quality domain
Our quality priorities
for 2013/14
Success measures
Monitoring
and reporting
responsibilities
Best patient
experience
To identify patient
experience champions
Staff identified to lead the ‘Making Every Contact
Count’ initiative within the unit
Clinical
Governance and
Risk Management
Committee (CGRMC)
Patient champions to identify and deliver two projects
to enhance patient care within the Day Case Unit
To meet the national
risk assessment for falls
prevention and supporting
patients with dementia
To achieve the national Commissioning for Quality and
Innovation (CQUIN) on dementia – staff to be trained
in dementia awareness, undertake assessment, and
refer patients on to support services where identified
To achieve local CQUIN on falls risk assessments, ensuring
that patients at risk are identified and harm is prevented
Best clinical
outcome
To undertake robust ‘Ready
for Operations’ assessment
for all new procedures
within the unit
All new procedures to undergo relevant risk assessment to CGRMC
identify potential risks and ensure controls are in place
Novel techniques process to be undertaken where required
Staff training to be in place
Patient information updated to ensure all patients
have information at time of discharge from the unit
Staff trained to safely use new equipment
Clinical buddies identified to support the wider team
in safely transferring activity to the treatment centre
To improve compliance with the Debrief to occur in 85% of operating theatre activity
debrief, following all operating
theatre lists
To ensure patients are treated
within a timely manner
To ensure all patients are treated within the
18-week Referral to Treatment
To ensure all patients who are cancelled by provider
are treated within 28 days
To reduce ‘did not attends’
Most engaged staff
To improve staff recruitment
and retention
To identify Circle Operating
System (COS) champions within
the unit to embed the process
To ensure establishment required maintains at 85%
To undertake establishment six-monthly reviews
against proposed activity
Ninety per cent staff identified to undergo training to
enable them to cascade the process to team members
COS local champions to lead for each area of the COS
COS local champions to identify case studies to be
shared both within the treatment centre and corporately
CGRMC
Patient, CircleNottingham
“Consultant was excellent. He explained
everything and allowed me to ask
questions. I was seen on time, and
greeting was very good.”
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Clinical unit
Quality Accounts
Continued
CircleNottingham Quality Account 2013/14
Endoscopy
About the clinical unit
The endoscopy service is situated in Gateway H of the Nottingham NHS Treatment Centre,
where we have delivered the best quality care to 11,100 patients; an increase in activity of
10% from last year. This is not unexpected based on changes to national initiatives and
bowel cancer awareness campaigns. Our patients receive care in our state-of-the-art suites,
equipped with a modern, high-definition video endoscopy system. The unit has a preassessment and telephone pre-assessment service, eight admission rooms, separate male
and female pre-procedure waiting areas, two enema rooms, a recovery area with nine beds,
a discharge lounge and three quiet rooms. We have a live link from one procedure room in
order to provide an excellent training facility for nursing and medical staff. We also have
on-site decontamination facilities so that our equipment can be sterilised quickly and
efficiently. Care is delivered by 16 endoscopists, 6 nurse endoscopists, 21 nurses and 17
healthcare assistants, who are supported by 9 administration staff.
We were very proud to have achieved JAG accreditation in 2012. In April 2013, we
undertook the required self-assessment, supported by the submission evidence against the
key performance indicators, and were informed in November 2013 that we had retained JAG
accreditation. This is a national award given to endoscopy departments that reach a gold
standard in various important aspects of their service, including patient experience, clinical
quality, workforce and training. We are now one of less than 10% of independent units in
the UK to have achieved the award so far, and we are aiming to ensure our excellent levels
of care continue and are improved upon year on year.
Achievement against quality improvement objectives 2013/14
Quality domain
Our quality priorities
for 2013/14
Outcomes
Status
Best clinical
outcome
Change practice to use carbon
dioxide inflation of the bowel
for lower gastrointestinal
procedures rather than
using air
The use of carbon dioxide for bowel inflation
has been introduced into the service. Its purpose
is to reduce the complications following lower
gastrointestinal procedures, including reduced
discomfort and recovery time
Achieved
Comfort scores are collated against each endoscopist.
During 2013/14, the comfort scores for colonoscopy
and flexible sigmoidoscopy averaged around 90%
Best patient
experience
Undertake a pilot study of
ENTONOX® use for sedation
and analgesia within the
endoscopy unit
This has been introduced and now forms
part of the sedation and analgesia offered
Achieved
Most engaged staff
Become a placement hub where
student nurses are linked to the
treatment centre for one year
of their training
We have successfully gained hub placement
recognition, provided mentorship training for
nurses, and provided placements and learning
opportunities for student nurses
Achieved
Feedback from the students:
• Friendly and inviting team
• Gave me confidence
• Good learning opportunities
• Fantastic and supportive mentors
• Gained knowledge on endoscopy
and gastric conditions
• Very good at patient-centered care
• Structured approach to learning
• I will be forever grateful for such
a high-quality placement
• A very hands-on placement which
allows students to be involved in all areas
• Would like to thank the team for giving me the
opportunity to work with them and teaching
me their valuable skills
We have worked closely with our neighbouring trust to develop a hub and spoke model to
support the national bowel screening programme. The guidelines for this service have been
developed and agreed across the East Midlands, and provide patients with a standardised
approach no matter where they are treated. These guidelines determine safe staffing levels,
the competency level of the screeners, and the timescales in which patients should be seen.
We have reviewed our service to ensure that our staffing levels link to our long-term goals.
We have worked closely with the University of Derby and have provided 16 student nurses
with a placement. This has resulted in the recruitment of 12 newly qualified nurses over this
time. The students work with us in a supernumerary capacity, having access to a structured
preceptorship programme, giving them specialist training from the endoscopy nurses and
experience in the provision of intravenous medication, cannulation, nurse-led consent,
and the use of ENTONOX® for pain relief.
Services provided
Colonoscopy, flexible sigmoidoscopy, gastroscopy, polyp removal, haemorrhoidal
banding, cystoscopy, endoscopic mucosal resection for polyp removal, varices banding,
bronchoscopy, gastrointestinal luminal stricture dilatation, argon beam ablation for the
oesophagus, and BOTOX® injection for achalasia of the oesophagus.
Learning from clinical audits
The learning that has been implemented as a result of the clinical audits undertaken
within the clinical unit is as follows:
• Each individual endoscopist’s audit results are sent to the clinical lead on a six-monthly
basis to review and ensure that levels of practice are within national guidelines.
• The audits for repeat endoscopy for gastric ulcers and correct position of colonic
tumours ensure we are following best practice and patients receive the best care
possible at all times.
• An annual patient survey is reviewed and an appropriate action plan developed,
with results acted upon within three months.
• Bowel preparation is audited to ensure lower gastrointestinal procedures produce
the best possible result.
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CircleNottingham Quality Account 2013/14
Clinical unit
Quality Accounts
Continued
Quality review of 2013/14
Best patient experience
Best clinical outcome
Patients likely to recommend the service (net promoter score)
Most engaged staff
Staff turnover
85.3
1.5%
Patients who responded to the Friends and Family Test
Vacancies as percentage of headcount
39.9%
4.5%
Formal complaints and concerns
Mandatory training – direct hire
9
71.8%
Unplanned transfers
0.2%
Incidents reported against activity
1.6%
Stop the Line events
5
The Commissioning for Quality and Innovation requires endoscopy units to achieve a
30% response rate of the Friends and Family Test in 2014/15. We have already exceeded
this target, obtaining a 39.9% response rate from our patients and a high net promoter
score of 85.3, indicating that our patients are likely to recommend us. We also undertake
an annual patient satisfaction survey as part of our JAG accreditation suite of audits. We
sent 150 questionnaires out to our patients with a return rate of 43%. The questionnaire
asked for their experience of booking an appointment, the environment, privacy and dignity,
information provided and aftercare.
Results were:
• Hospital and unit facilities – the majority of patients rated this as excellent/good.
• Booking appointments – only two patients felt the appointments did meet their needs.
• Information – 95% of patients found the information satisfactory; 90% of patients
thought they were able to ask questions.
• Consent – 98% of patients felt completely informed.
• Post-procedure care – 98% felt that they were given the opportunity to discuss their
procedure in confidence.
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Clinical unit
Quality Accounts
Continued
CircleNottingham Quality Account 2013/14 83
We are delighted that our staff have identified five Stop the Line events, which demonstrates
that they are risk-aware and aim to improve the environment that they work in. The Stop
the Line events have been:
• Lack of capacity to consent, language barrier and eligibility for NHS healthcare –
legal clarification was sought and the Mental Capacity Act test undertaken. • Insufficient information from another provider to determine patient’s suitability for
treatment in a day case setting – clarification provided to referring clinician to enable
decision to be made.
• Decontamination unit daily total viable count exceeding expected levels – unit was taken
out of use, deep cleans undertaken, consideration given to replacement of machines as
they are now five years old.
• Decontamination drying cabinet malfunction – changes to process and standard operating
procedures to provide greater clarity, additional staff training provided and dedicated
decontamination team leader identified. During 2013/14, staff turnover remained stable; however, in January 2014, we had five
vacancies which were recruited to in a timely manner.
Quality improvement priorities for 2014/15
Quality domain
Our quality priorities
for 2013/14
Success measures
Monitoring
and reporting
responsibilities
Best patient
experience
Include endoscopy report
in patient’s discharge pack
Pilot study to establish whether patients require
the endoscopy report and are clear about its content
Ensure patients understand
the endoscopy report which
is provided to them as part
of their patient information
Develop a frequently asked questions leaflet
for patients
Clinical
Governance and
Risk Management
Committee (CGRMC)
Provide ‘direct to test’
service for two-week wait
colonoscopy patients
Reduction in cancer pathway with shortened
time scales to diagnosis.
Engage and empower our staff
to contribute to the national
‘paper light’ agenda, which
will reduce the burden on the
environment and ensure that
patient information is electronic
and accessible for those caring
for the patient
Develop a programme of initiatives:
Best clinical
outcome
Most engaged staff
Re-audit patient’s understanding to ascertain
if the leaflet improves patient understanding
CGRMC
• Audit of current timescales to diagnosis
• Implementation of ‘direct to test’ service
• Re-audit of timescales
CGRMC
• Text reminder service for appointments
• Feedback obtained via tablet
• Meeting papers to remain electronic
• Electronic requests to be printed
double-sided (reconfiguration of printers)
Patient, CircleNottingham
“The care and attention to detail is
exceptional, from the internal waiting
rooms to the friendly staff. Everything
was explained well.”
84 CircleNottingham Quality Account 2013/14
Clinical unit
Quality Accounts
Continued
CircleNottingham Quality Account 2013/14
Digestive diseases
About the clinical unit
The digestive diseases and urology outpatient clinical unit provides safe, professional
and discreet care to approximately 30,000 patients each year who have presented with
health concerns of a sensitive nature. We provide access to a range of interlinked specialties
which are outlined below. Due to the high volume and complex and diverse nature of this
outpatient unit, we have increased the working day to provide appointments until 8pm
to accommodate the growing demand.
Achievement against quality improvement objectives 2013/14
Quality domain
Our quality priorities
for 2013/14
Outcomes
Status
Best clinical
outcome
Ensure timely ordering of
diagnostics investigations
Patients identified in endoscopy with IBD are seen
at the same appointment by a specialist IBD nurse.
Patients are then provided with a treatment plan at
this stage and are followed up in clinic
Achieved
Inflammatory bowel disease
(IBD) patient pathway developed
to enable those requiring urgent
appointments are seen in a
timely manner. Patients have
access to IBD nurse specialists
for advice. Nurse-led clinic
and telephone appointments
for follow-up patients with
availability of annual followups in the community and
self-management plans to allow
access for urgent appointments
with clinicians as required
We are committed to ensuring our patients are treated with respect, compassion and
dignity, to ensure they feel confident they have received the best treatment and advice.
We understand that each patient has their own unique concerns and questions, and our
aim is to ensure that the treatment and advice given fulfils their needs. We have a large
cohort of national and international experts in digestive diseases who are at the forefront
of education. We are involved in active research studies in all disciplines, including upper
and lower gastrointestinal, as well as liver disorders.
We are also fully committed to providing graduates and undergraduates with medical
and nursing training, offering them a wide and varied insight into the specialty. Continuity
of care for digestive diseases is maintained by working closely with endoscopy to ensure
a seamless pathway for patients. This is also enhanced by staff rotation throughout
both units.
This year, we have introduced a comprehensive inflammatory bowel disease service with
three dedicated specialist nurses. Due to the increased capacity, we have been able to see
more patients in our clinic; we have also provided a dedicated telephone follow-up service
so that patients do not have to make a special journey to be seen. The service has also
introduced an anti-inflammatory infusion treatment, which now provides a seamless
pathway from consultation to treatment. Patients are now treated in the same building
by the same staff, ensuring improved continuity of care.
Best patient
experience
Services provided
Digestive diseases
Colorectal, gastroenterology, hepatology, pre-assessment clinic for endoscopy,
faecal incontinence/sacral nerve stimulation, and functional bowel disease services.
Urology
General Urology Clinic, flow rate measurement, bladder scanning, transrectal ultrasound,
and biopsy of the prostrate gland.
Rapid access clinic has been set up on Friday
afternoons for patients experiencing flare-ups,
with access to specialist clinicians. This has
resulted in fewer admissions at weekends
Long-term follow-up patients – a shared care
protocol is partly developed with the clinical
commissioning group
We are developing our
endoscopy pre-assessment
service further to ensure the
majority of patients undergoing
a procedure are given the
appropriate information and
have their concerns answered
prior to their appointment
date. We are increasing our
pre-assessment staffing levels
to incorporate an increase in
telephone and face-to-face
appointments available
The pre-assessment service was established in 2013/14;
however, during October to February, this service was
not sustainable as three nurses moved into the IBD
service. We have recruited into the posts and the
service has now resumed
Partially achieved
Clinicians reviewing
diagnostic results
consistently in a
timely manner
We have worked with the clinicians to develop an
outcome form to indicate which tests will be carried
out. These are recorded on our patient administration
system, and monitored and actioned daily
Achieved
Medical secretaries now hold a tracking database
of all outstanding tests and chase the results to
ensure timely review
Dedicated space has been allocated for the doctors
to review the diagnostic results
Most engaged staff
Healthcare assistant (HCA)
training to be developed to
become more specialty-based,
considering needs of staff
Competency pack has been developed for all HCAs
and has been completed by the majority of our staff
HCA training is in place via a clinical skills trainer.
Some HCAs still need to attend training
Partially achieved
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Clinical unit
Quality Accounts
Continued
CircleNottingham Quality Account 2013/14
Clinical audit
The unit has undertaken two consent audits which monitor clinician compliance with the
two-stage consent process, ensuring that patients have had the opportunity to consider
all the information provided to them before deciding to go ahead with their procedure.
In January 2014, compliance with the two-stage process was 75% and, by March 2014,
this had increased to 98%.
Quality review of 2013/14
Best patient experience
Best clinical outcome
Patients likely to recommend the service (net promoter score)
Most engaged staff
Staff turnover
81.2
1%
Patients who responded to the Friends and Family Test
Vacancies as percentage of headcount
11.8%
8.4%
Formal complaints and concerns
Mandatory training – direct hire
22
77.7%
Incidents reported against activity
0.31%
Stop the Line events
0
Although we strived to achieve a 20% patient feedback response rate, we did not quite achieve
this, primarily because we are a high volume unit. However, we did receive feedback from
approximately 3,500 patients for this time frame. We were already aware that our patients
felt the wait to see their consultant was longer than they would have liked. We had already
increased the length of time for our clinic slot so that patients were given more time in their
consultation. This year, we decided to improve communication and let our patients know if
there was a delay. We now see positive comments about keeping our patients well informed
and we feel that this is reflected in our net promoter score of 81.
We actively seek feedback from our patients and ensure that they are informed about
how to raise concerns. This has resulted in 22 complaints and concerns being raised in
this time period; however, this figure accounts for only 0.07% of our activity; a percentage
comparable to other services within the treatment centre. We have noted that a number
of these concerns have identified breakdown of communication as a recurring theme,
in particular patient pathways that span other services and hospitals. This has resulted
in delays in information reaching the patient or lack of clarity around the stage of their
treatment. We are currently piloting an information leaflet that informs the patient of
what tests they have undergone, how long the results should take, and instruction of
who to contact if the time period is exceeded.
The workforce within the gateway has remained stable; however, when the treatment
centre established its own medical secretary service, a number of the administration staff
from Gateway I requested transfer. Therefore, the vacancy headcount increased for a short
period of time. The vacant posts were subsequently recruited to.
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Clinical unit
Quality Accounts
Continued
Quality improvement priorities for 2014/15
Quality domain
Our quality priorities
for 2013/14
Success measures
Monitoring
and reporting
responsibilities
Best patient
experience
Provide anti-inflammatory
infusions for our inflammatory
bowel disease patients, so that
the service is streamlined and
the patient pathway remains
with one provider
Increased activity month on month
Clinical
Governance and
Risk Management
Committee (CGRMC)
Introduction of group
sessions for patients
requiring dietary advice
Reduction in waiting times for appointment,
and improved access with improved choice
Best clinical
outcome
Improve new to follow-up ratio
for colorectal patients in line
with national protocol. The
severity of disease will indicate
the treatment options and
therefore follow-up criteria
Follow-up criteria to be developed
Most engaged staff
We will invest in our healthcare
assistants (HCAs) by providing
them with specialty training
and an opportunity to develop
their skills
Dedicated training to be introduced
Patient satisfaction net promoter scores
Service evaluation
Better clinical outcomes as advice is
provided sooner
CGRMC
Measure each consultant against
new to follow-up ratio
CGRMC
• Healthy liver course
• Transrectal ultrasound biopsies (assisting)
• Faecal incontinence awareness for HCAs with
a dedicated individual to support manometry
Patient, CircleNottingham
“Prompt and
friendly staff at
all levels. Seen
by consultant
very quickly;
no waiting.”
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CircleNottingham Quality Account 2013/14
Part four
Patient, CircleNottingham
“Prompt attention; courteous;
efficient; spotlessly clean facility.”
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CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
Statement from the
Patient and Public
Engagement Group
Statement from NHS
Rushcliffe Clinical
Commissioning Group
The Patient and Public Engagement Group is delighted to have been invited to contribute
to the CircleNottingham Quality Account for 2013/14. We welcomed the opportunity to be
part of the planning sessions for the Quality Account, and this has enabled us to contribute
to the quality improvement priorities for the coming financial year. As both members of
the Patient and Public Engagement Group and, in some cases, patients ourselves, we felt
we represented the ‘voice’ of the community and that our opinions and thoughts were
a valuable contribution to the quality agenda for 2014/15.
Rushcliffe Clinical Commissioning Group (CCG) is the co-ordinating commissioner for
CircleNottingham (independent sector treatment centre) for 2013/14 on behalf of a
number of commissioners. In this role, the CCG took on responsibility for monitoring
the quality and performance of services at CircleNottingham from June 2013. The CCG
is satisfied that the information contained within this quality account is consistent with
that supplied to us throughout the year.
All members of the Patient and Public Engagement Group have had the chance to be
an integral part of the clinical unit partnership session, contributing valuable insight of
the services from a patient perspective. This has provided us with a unique opportunity
to work jointly with clinicians and other healthcare staff to consider how their services
can work better, offer valuable patient perspectives and support the development of
improvements. We have been openly welcomed by the clinical units, and the doctors,
nurses and administrative staff have worked with us to learn from our experiences and
meet our challenges.
2013/14 has been both an exciting and dynamic year for the Patient and Public
Engagement Group, and we have worked jointly with CircleNottingham to contribute
to the development of the website, develop the rheumatology helpline, comments on the
template for appointment letters, contribute and comment on the patient journey television
presentation and work on the content and introduction of the patient experience tablet.
We look forward to continuing the programme of joint working, and we are excited
about the development opportunities that will arise as CircleNottingham develops
and grows its services.
Mr Stephen Hyde
Chair
Patient and Public Engagement Group
There are a number of ways in which we review and monitor the performance and
quality of the services we commission. This includes quality visits to services, regular
quality and contract review meetings, and continuous dialogue as issues arise; for
example, about patient safety incidents or patient feedback. These mechanisms
allow us to triangulate and review the accuracy of the information being presented
to formulate opinions about the quality of services provided to patients at both
organisation and service level.
We commend CircleNottingham for its governance structure, which promotes staff
engagement and ownership within each clinical unit, and is evidenced by the clinical
unit specific information in this Quality Account. This enables clinicians closest to
the patient to work as a team to self-regulate the quality of their service, whilst being
accountable and reporting centrally to an organisational Clinical Governance and Risk
Management Committee (CGRMC), which reports to the CircleNottingham Board. In
addition, this enables each clinical unit autonomy to set objectives to improve quality
which are specific to the patient group and clinical context of the area.
CircleNottingham has worked constructively with commissioners and other partners
to respond to local commissioning intentions and develop integrated care pathways that
reduce inequality and improve the health of Nottingham and Nottinghamshire residents.
Effective relationships have been developed between the new co-ordinating commissioning
team in Rushcliffe CCG and the senior team at CircleNottingham.
The Care Quality Commission (CQC) visited CircleNottingham in September 2013 for
an unannounced visit due to concerns raised about standards of safety and quality not
being met in skin surgery and day case. Inspectors felt that there were two of five outcome
measures which required action and these were in relation to supporting workers and record
keeping. CircleNottingham has proactively addressed these concerns by developing an
action plan for improvement which the CQC are monitoring. CircleNottingham has also
been working closely with the CQC and the commissioning team to facilitate the development
and opening of 11 short stay inpatient beds, which improves continuity of care and a wider
range of access for patients.
CircleNottingham has a good ethos of reporting incidents internally and reviewing themes
and key learning, both in the clinical unit and up to the CGRMC. Of the one serious incident
reported on the Strategic Executive Information System (STEIS), there was a full review and
no actions were required by CircleNottingham, as they had done everything correctly.
CircleNottingham has a very proactive approach which encourages staff to take patient
safety as paramount, and is evidenced by their engagement and support of ‘Stop the Line’.
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94 CircleNottingham Quality Account 2013/14
Statement from NHS
Rushcliffe Clinical
Commissioning Group
Continued
CircleNottingham Quality Account 2013/14
We have been working with Circle to support their improvement in continuous quality
improvement, and the CQUINs for 2013/14 have been embraced with demonstrable progress
against them. We are especially pleased with the participation by CircleNottingham in the
CQUIN related to complaints management, which has meant taking part in an external
peer review from the Patient Association and taking forward recommendations as a result.
CircleNottingham continually demonstrates good patient engagement and feedback, as
can be seen by the Friends and Family Test results. They have widened their opportunity to
capture patient experience by utilising patient representatives, undertaking a ‘Compassionate
Care Audit’ (CQUIN), and piloting electronic tablets, as well as postcards which patients
are encouraged to complete. This Quality Account demonstrates how patient feedback
has altered care delivery and processes in CircleNottingham to enhance experience.
It is expected that the relationship between the co-ordinating commissioner and
CircleNottingham will continue to develop over the forthcoming year of 2014/15,
and that achievement against quality indicators, including performance and contractual
requirements, will be monitored and agreed collaboratively. We look forward to
CircleNottingham finding a mechanism to be able to ensure its information on
quality (primarily patient experience, outcomes and safety) will be available for
the public on their website to enhance transparency and accountability to the
patients they serve.
Vicky Bailey
Chief Officer
NHS Rushcliffe Clinical Commissioning Group
June 2014
Statement from the
Joint Nottingham and
Nottinghamshire Health
Scrutiny Committee
The Joint Health Scrutiny Committee welcomes the opportunity to comment on the Circle
Nottingham NHS Treatment Centre Quality Account 2013/14. Our comment focuses on the
areas in which we have engaged with the organisation during 2013/14.
During the year, members of the committee visited the treatment centre, including the new
Short Stay Unit. Councillors were impressed by the facilities available in the unit, but at the
time of the visit, the unit hadn’t yet been used by patients overnight so it wasn’t possible
to get patient feedback.
Councillors were pleased to note that the treatment centre has had zero ‘never events’
during 2013/14, and particularly pleased to see that the net promoter score (the Friends
and Family Test) is 83.4.
With reference to the dermatology Quality Account, councillors were pleased to see the
high level of responsiveness which arose from an incident that highlighted the need for
training on mental capacity issues, and that take-up of your mandatory mental capacity
training is currently over 90%.
Regarding the day case Quality Account, councillors note that the development of a dignity
passport into the care pathway was put on hold while the treatment centre concentrated on
improving staffing levels. Councillors hope that this piece of work will be developed as soon
as is practicable.
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96 CircleNottingham Quality Account 2013/14
CircleNottingham Quality Account 2013/14
Jargon buster
Credo
A set of fundamental beliefs or a guiding principle. For Circle, a credo is similar
to a mission statement that guides the way in which we deliver healthcare
IRMER
Ionising Radiation (Medical Exposure) Regulations
Joint Advisory Group (JAG)
The Joint Advisory Group on gastrointestinal endoscopy (JAG) operates within the Clinical
Standards Department of the Royal College of Physicians. JAG has a wide remit and
its core objectives include: to agree and set acceptable standards for competence in
endoscopic procedures; and to quality assure endoscopic units, training and services
NCAPOP
National Clinical Audit and Patient Outcomes Programme
NICE
National Institute of Clinical Excellence
NPS
Net promoter score
Partnership sessions
Educational, discussion and solution-focused sessions held within clinical units and
open to all staff involved in the patient pathway. The purpose of the sessions is to
improve competence and educate staff, enable discussions of any issues that have
arisen, and provide the opportunity to develop realistic and effective solutions
Peer review
A process of self-regulation by a profession or a process of evaluation involving qualified
individuals within the relevant field. Peer review methods are employed to maintain
standards, improve performance and provide credibility
PROMs
Patient reported outcome measures
SWARM
A term used to refer to a gathering of the relevant staff in order to discuss proposed
solutions and agree actions following an issue which has arisen. This is part of our
Circle Operating System methodology
WHO
World Health Organisation
Patient, CircleNottingham
“Brilliant experience!
I was well looked after.”
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98 CircleNottingham Quality Account 2013/14
Thank you
Thank you for taking the time to read our Quality Account. We hope
you found it interesting and useful in understanding our commitment
to quality for our patients and partners.
Should you have any further questions, we would be pleased to hear
from you.
Please contact us on nottingham@circlepartnership.co.uk.
Our credo
Our purpose To build a great company dedicated to our patients.
Our parameters We focus our efforts exclusively on what we are
passionate about. What we can become best at. What drives our
economic sustainability. Our principles We are, above all, the
agents of our patients. We aim to exceed their expectations every
time so that we earn their trust and loyalty. We strive to continuously
improve the quality and the value of the care we give our patients.
We empower our people to do their best. Our people are our greatest
asset. We should select them attentively and invest in them passionately.
As everyone matters, everyone who contributes should be a partner
in all that we do. In return, we expect them to give their patients
all that they can. We are unrelenting in the pursuit of excellence.
We embrace innovation and learn from our mistakes. We measure
everything we do and we share the data with all to judge. Pursuing
our ambition to be the best healthcare provider is a never-ending
process. ‘Good enough’ never is.
Patient, CircleNottingham
“I was really terrified, but
constantly reassured by
the staff. Beautiful place,
and staff are lovely.”
CircleNottingham
Nottingham NHS Treatment Centre
Queen’s Medical Centre Campus
Lister Road
Nottingham
NG7 2FT
circlenottingham.co.uk