Quality
Account
2014/15
What is
a quality
account?
A Quality Account is an annual report about the quality
of services provided by an NHS healthcare organisation.
Quality Accounts aim to increase public accountability
and drive quality improvements in the NHS. Our
Quality Account looks back on how well we have
done in the past year at achieving our goals.
It also looks forward to the year ahead and defines
what our priorities for quality improvements will be
and how we expect to achieve and monitor them.
Glossary Symbol
This symbol  indicates a term's
inclusion in the glossary on p68
Contents
Part 1: Statement from the Chief Executive
4
Part 2: Our priorities and statements of assurance
8
2.1 Our priorities
8
2.1.1: How well have we done in 2014/15?
10
Safety
12
Clinical Effectiveness
18
Patient Experience
24
2.1.2: What are our priorities for 2015/16?
30
Safety
32
Clinical Effectiveness
34
Patient Experience
36
2.2: Statements of assurance
38
Information on the review of services
38
Information on participation in clinical audit
38
Information on participation in clinical research
39
Information on the use of the CQUIN framework
44
The Care Quality Commission
44
Quality of data
47
Information Governance
47
Clinical coding
47
2.3: Reporting against core indicators
50
Part 3: Other information
54
Annex 1: Statement from stakeholder organisations
58
Annex 2: Statement of directors' responsibilities
66
Glossary
68
1
Statement from the Chief Executive
5
1 | Statement from the Chief Executive
Welcome to the quality account for 2014/15.
Our vision is to provide safe, effective and personalised care
- every patient, every time. The aim of our Quality Account
is to give our patients, families, stakeholders and the public
clear information about the quality of our services. We seek
to give an honest, transparent account of our performance,
sharing where we are doing well and where we still have
work to do on our journey of quality improvement.
This report is intended to provide an overview of our
performance in relation to the three dimensions of quality:
\\
Safety
\\
Clinical effectiveness
\\
Patient experience
Each section of the report will explore how well we
have achieved our ‘quality priorities’ for 2014/15
and what we intend to do in the year ahead.
This past year has seen our staff rise to the many challenges
we have faced together and I would firstly like to thank
them all for their contribution and the fantastic effort they
have personally made in improving care for our patients.
It has been a tough 12 months. Like many NHS hospitals
across the country, we continue to treat an increasing
number of patients in our Emergency Departments and are
admitting a high number of emergency medical patients,
putting front-line staff under real pressure. At the same
time, patients who are ready to leave hospital (known as
‘medically fit’) are often left waiting in a hospital bed while
arrangements for their ongoing care in the community are
made. These combined pressures have placed significant
strain on our services during 2014/15 and cannot be
solved by a hospitals trust alone. We will be working
closely with our partners in other NHS and social care
organisations in Gloucestershire in the year ahead to make
sure that we can provide a high quality health service that
treats patients in the right place and at the right time.
These pressures have had an inevitable impact on our ability
to meet some of our own, and national, standards. The
target to see, treat and admit or discharge every patient
that attends one of our Emergency Departments (A&E)
within four hours of their arrival has been particularly
challenging due to the rising demand on this service.
Despite the pressures we have faced this year, we
have nonetheless continued to make some excellent
improvements in the quality of care our hospitals
deliver. In the final quarter of the year 95% of
inpatients who responded to the Friends and Family
Test said they would recommend our services.
We have continued during 2014/15 to focus on our culture
of safety and ensuring that our organisational values
can be demonstrated every day in the care we give to
patients. Each year we introduce new ideas and methods
for safety improvement and each year we see the results
of these efforts - from dramatically reducing the incidence
of infections such as MRSA or Clostridium difficile, to
improving the chances of surviving sepsis. More information
about our safety initiatives can be found on p12.
The quality of our clinical leadership is another clear
strength for our hospitals, with senior doctors and nurses
taking the lead in key decision making for both their own
areas and in wider trust developments and making time to
lead their teams. A good example of this is the SmartCare
programme which has been shaped around the needs of
clinical staff. You can read more about this project on p22.
In response to the 2013 NHS England ‘Compassion in
Practice’ strategy and the publication of the Francis
Report recommendations, we have implemented
a number of initiatives to ensure we are able to
deliver consistent, compassionate care. More
information about this work can be found on p27.
These areas of strength, as well as where we need to
improve, were highlighted to the Care Quality Commission
during their visit in March 2015. At the time of writing we
are still awaiting the formal outcome of their visit, the first
of their new inspection regime. At our Trust we encourage
people to both share good ideas and raise concerns where
they arise so that we can turn these experiences into
improved patient services and a better working life for our
staff. This year we have introduced a new online feedback
tool, called Speak in Confidence, which allows staff to raise
concerns anonymously and we hope that this will further
encourage our staff to raise any issues they may have.
It is clear from the results of our staff survey that
the work we have been doing to address the issues
raised in 2013 are having a positive effect, but that
there is still more work to do. The survey shows that
our staff are feeling satisfied with the quality of work
and patient care they are able to deliver for example,
and believe that we provide equal opportunities for
career progression. While the violence and aggression
experienced by staff from patients has fallen slightly
since 2013, our score is still above the national average
so we know more must be done to protect our staff.
During 2014/15 our Trust has continued to strengthen
the quality of care we provide for our patients. Our staff
consistently demonstrate their commitment to delivering
safe, effective, compassionate and personalised care for
their patients, even during periods of increased pressure.
I hope that readers of this document find it accessible
and informative and I would like to thank everyone
who contributed to its development, including
members of the public, our own Trust Governors,
Healthwatch Gloucestershire, Gloucestershire
Health and Care Overview and Scrutiny Committee
(HCOSC) members and commissioner colleagues.
6
1 | Statement from the Chief Executive
I can confirm that to the best of my knowledge
the information included in this document has
been subject to all the appropriate scrutiny and
validation checks to ensure the data is accurate.
Dr Frank Harsent
7
1 | Statement from the Chief Executive
Next part:
Our priorities and statements of assurance
2
Our priorities and
statements of assurance
2 | Our priorities and statements of assurance
Helping us improve the
quality of care.
Each year our Quality Committee agrees a
set of priorities which help us improve the
quality of care we provide for our patients.
Some of these priorities are identified because they
are important to our regulators and/or commissioners.
However most are decided following discussions
with our Council of Governors, the Gloucestershire
Health and Care Overview and Scrutiny Committee
(HCOSC)  and the Gloucestershire Healthwatch .
The following section is divided into four parts:
\\
How well have we done in 2014/15: looks
at what our priorities were during 2014/15
and whether we achieved the goals we set
ourselves. Where performance was below what
we expected we explain what went wrong and
what we are doing to improve (see p10)
\\
What are our priorities for 2015/16: explains
why these priorities have been identified
and how we intend to meet our targets for
these during the year ahead (see p30)
\\
Statements of assurance from the
Board (see Section 2.2 p38)
\\
Reporting against core indicators (see p50).
The second two parts give an overview of the
range of services we provide and give some context
to the data we provide in section three.
The Quality Committee is responsible for monitoring
the progress of the organisation against our quality
improvement priorities. The Committee meets eight
times a year and reviews a series of measures which
give us a picture of how well we are doing.
The Quality Committee is a sub-committee of the Board
and has clinical and managerial representation from across
our Trust. It includes non-executive directors, executive
directors, governors , representation from Gloucestershire
Clinical Commissioning Group and during 2014/15 was
chaired by Helen Munro, Non-Executive Director.
9
2.1.1
How well have we done in 2014/15?
The table opposite provides an overview of our
quality priorities for 2014/15. The table gives you
an at-a-glance view of the work undertaken in the
past year and which of our stakeholder groups
identified it as an issue to be addressed.
11
2.1 | How well have we done in 2014/15?
Priorities for improving quality in 2014/15
Incomplete
from last year
National priority
for 2014/15
Issue for
commissioners
/ CQUIN
NHS Safety Thermometer



Management of Sepsis

Never events


Improving patient flow


Priorities
Issue for
HCCOSC
Issue for
Healthwatch
Issue identified
internally inc.
govenors
1. Safety



Seven day working

Reducing violence and aggression

2. Clinical Effectiveness
Dementia and delirium

Chronic Obstructive Pulmonary
Disease

Acute Kidney Injury




Reducing variation

3. Patient Experience
Friends and Family test

Learning from feedback

Involving patients in
service improvement
Delivering compassionate care
Cancer waiting times














2.1.1
How well have we done in 2014/15?
Safety
Implement the NHS Safety Thermometer 
The NHS Safety Thermometer was developed as
a survey tool that allows hospitals to measure the
proportion of patients that are ‘harm free’ during
their stay. It is based around four key nationallyrecognised indicators of harm to patients:
Even with the highest standards of care it is not always
possible to prevent ulcers in particularly vulnerable
people. However, 95% of all pressure ulcers are
completely avoidable, if the right steps are taken by our
nursing teams. Our staff are taught that by turning and
moving patients regularly, making sure any incontinence
is well managed and that patients are well fed and
hydrated, they are unlikely to develop an ulcer.
\\
pressure sores
\\
falls
This year our CQUIN  targets were:
\\
venous thromboembolism (VTE) 
\\
\\
urinary tract infections in patients with a catheter
to have action plans in place to reduce ulcers in our
General Old Age Medicine (GOAM) wards and Acute
Care Units (ACUs). Older people cared for in the
GOAM wards are more vulnerable to pressure sores
and opportunities to identify pressure ulcers among
patients in the short-stay ACUs can be missed
\\
to track the origin of any pressure sores once
identified to establish whether they developed
in our hospitals or in the community eg in their
own home or in a community hospital
\\
to carry out a root cause analysis for all Grade
3 and 4 pressure ulcers. Grades 3 and 4 are the
most serious pressure ulcers, and it is important
that we find out how the ulcer developed so
that we can improve care for future patients.
These conditions affect more than 200,000 people
each year in England alone, leading to avoidable
suffering and additional treatment for patients. The
‘harm free’ care programme aims to eliminate these
four avoidable conditions through one plan.
Every acute trust is required to measure the percentage
of its patients who receive harm free care on a monthly
basis. In 2014/15 the percentage of patients who received
harm free care in our hospitals was an average of 94%.
Again this year, our focus has been on reducing
the number of pressure ulcers (also known as
pressure sores) affecting patients in our care.
Pressure ulcers are an injury that breaks down the skin and
underlying tissue. They are caused when an area of skin
is placed under pressure and develop over a short period
of time. Pressure ulcers tend to affect people with health
conditions that make it difficult to move, especially those
confined to a bed or sitting for long periods of time.
For some patients, pressure ulcers are an inconvenience
that require minor nursing care. For others, they can
be serious and lead to life-threatening complications,
such as blood poisoning or gangrene.
We have achieved these goals and have done lots of work
to identify all pressure ulcers so that they can be properly
healed in our hospitals. In particular we have focussed on
the education of nursing staff, showing them how to use
the scoring system – called the Waterlow Score  – which
determines how at risk a patient is of developing an ulcer.
We have held a number of awareness-raising ‘Stop the
Pressure’ events, including a competition which encouraged
staff to share their ideas for good practice on their wards.
Winners were chosen by the Director of Nursing and the
Chief Executive and won M&S vouchers. The overall winner
was the Cardiology team at Cheltenham General Hospital.
First prizes also went to Prescott Ward, at Cheltenham
13
2.1 | How well have we done in 2014/15?
Fig. 1: Total number of pressure ulcers identified June 2012 - Jan 2015
20
Number
Trend
15
NUMBER
RE SORES
10
JUN-15
APR-15
MAY-15
MAR-15
FEB-15
JAN-15
DEC-14
OCT-14
NOV-14
SEP-14
JUL-14
AUG-14
JUN-14
APR-14
MAY-14
FEB-14
MAR-14
JAN-14
DEC-13
NOV-13
SEP-13
OCT-13
JUL-13
AUG-13
JUN-13
APR-13
MAY-13
FEB-13
MAR-13
JAN-13
DEC-12
OCT-12
NOV-12
SEP-12
AUG-12
JUL-12
0
JUN-12
5
General, and Ward 3b at Gloucestershire Royal Hospital.
We have also invested again this year in more pressure relief
equipment – air mattresses, seat cushions and speciallyadapted boots which help prevent the development
of pressure ulcers in patients who are at risk.
As Figure 1 shows, since June 2012, we have seen a
modest reduction in the pressure ulcers that develop
while a patient is in our care. It is interesting that within
the last two years, there has been a greater focus on
identifying and reporting pressure ulcers through our
incident systems. This may have increased awareness
and therefore the reporting of ulcers. We are not
complacent and the challenge of prevention continues
again in the year ahead. You can read more about our
plans to reduce pressure ulcers during 2015/16 on p32.
A screensaver used to support the Stop The Pressure campaign this year.
Improving the management
of patients with sepsis
Worldwide sepsis kills more than 1,400 people every
single day. In the UK alone it is estimated that more
than 37,000 people die every year. This means that
more people die each year from sepsis than from lung
cancer and from breast and bowel cancer combined.
Sepsis is a life-threatening condition that arises when the
body’s response to an infection injures its own tissues and
organs. Sepsis can lead to shock, multiple organ failure
and death, especially if not recognised early and treated
quickly. Each month our hospitals’ Emergency Department
treats between 40 and 50 patients with severe sepsis.
14
2.1 | How well have we done in 2014/15?
Since the management of patients with sepsis
was first identified as a national quality priority in
2010, we have had increasing success in improving
the care and outcomes for these patients.
This year our target has been to ensure that 90%
of patients diagnosed with severe sepsis are given
what is known as the Sepsis Six care bundle . The
Sepsis Six is a set of six tasks delivered by doctors
or nurses within one hour of diagnosis.
You can see how we have done against this target Figure
2. Despite making good progress in previous years,
our performance in 2014/15 has not met the target.
During 2014/15 our performance against the Sepsis Six
target was supported by an awareness campaign and
regular presence from the safety team in ward areas. Since
this introductory campaign finished, the performance has
dropped to a steady position of 80 - 85%. This shows us
that changes to the way we do things are needed if we are
to return to consistent acheivement of the 90% target.
These were:
\\
wrong site surgery
\\
inappropriate administration of daily oral methotrexate
\\
misplaced naso-gastric tube
When a never event has been identified, a thorough
investigation process is triggered immediately and the senior
clinician and executive Board members informed. The aim
of this investigation is to identify both the organisational
and human factors that led to the error. From this work we
identify what improvements are needed and then monitor
this action plan until it has been fully implemented.
Details of all investigations, their outcomes and
subsequent actions are always shared with the patient
involved in the original incident and, depending
on their preference, can include a face-to-face
meeting and explanation of what went wrong, and/
or a letter and copy of the investigation report.
Towards the end of the year, the national focus moved from
treating severe sepsis with the Sepsis Six , to making sure
patients with the early stages of sepsis receive the right care
early enough to prevent them developing severe sepsis.
The investigations into the second two never events
are still ongoing. A thorough investigation into
the 'wrong site surgery' event revealed that pre
and post-procedure safety checks were not always
carried out and so a check list was introduced to
minimise the risk of the incident happening again.
We now ask that all First doses of AntiBiotics should
be given within 60 minutes to sepsis patients,
whatever their condition. This is known as FAB 60.
Supporting patient flow
We carried out a pilot project in the Chemotherapy
Helpline Assessment Unit to see if this early intervention
of treatment for patients with sepsis would have
an impact on their health and care. Within three
months they saw their performance dramatically
improve. Our work has shown that good teamwork
between nursing, medical and pharmacy staff can
dramatically improve care for patients with sepsis.
The term ‘patient flow’ refers to the way our patients
move through the hospital, from their admission to when
they are discharged. We want to design efficient services
which allow our patients to move quickly through the
Emergency Department (A&E)  to a ward where the
staff are specially trained to deal with their particular
condition or illness, before discharging them – either to
their own home or to another appropriate care provider.
Improving care for patients with sepsis will
continue to be a CQUIN  for us in 2015/16.
Good patient flow allows us to provide safe, effective
care and gives patients the best possible experience of
our services. Conversely, research has linked poor patient
flow with increased mortality, an increased risk of adverse
incidents, readmissions and poor financial performance.
Reducing the incidence
of never events
Never events are very serious, largely preventable patient
safety incidents or errors that should not occur if the
relevant preventative measures have been put in place.
There are currently 25 types of incident which the
Department of Health has identified as never events.
During 2014/15 we had three never events at our Trust.
We measure our success at improving patient flow by
looking at several different indicators, including Length
of Stay (how long on average patients stay in the
hospital), Time of Discharge (what time of day patients
are discharged from hospital) and the four-hour wait
target (how many patients waited less than four hours in
the Emergency Department from arrival to discharge or
admission). Our performance is shown in Figures 3-5.
Improving patient flow has been a challenge for us during
2014/15 due to an increased demand on our services,
15
2.1 | How well have we done in 2014/15?
Fig. 2: Compliance with Sepsis 6 care bundle in the Emergency Department 2014/15
100
95
Target
90
Compliance
85
% COMPLIANCE
75
70
65
60
55
MAR-15
FEB-15
JAN-15
DEC-14
NOV-14
OCT-14
SEP-14
AUG-14
JUL-14
JUN-14
MAY-14
APR-14
MAR-14
FEB-14
JAN-14
DEC-13
NOV-13
0
OCT-13
50
Fig. 3: Monthly average length of stay for patients whose admission is unplanned 2014/15
8
7
Data
Target
6
5
3
2
MAR-15
FEB-15
JAN-15
DEC-14
NOV-14
OCT-14
SEP-14
AUG-14
JUL-14
0
JUN-14
1
MAY-14
NUMBER
4
APR-14
SEPSIS 6
80
16
2.1 | How well have we done in 2014/15?
felt both in our hospitals and in many others across the
country. On average, around 10% of our patients need
some form of care from the community when they leave
our hospitals. Sometimes these placements can be difficult
to arrange or delays in processing them occur. This then
means that patients who are considered to be ‘medically
fit’ and ready to leave are then waiting in a hospital bed
when they don’t need to be. This leads to a shortage of
beds and patients who need to be admitted through the
Emergency Department  are delayed while a bed is found.
However, there are things we can and are doing to improve.
We know that while attendances at the Emergency
Department  have increased, the number of patients
we need to admit to a hospital ward has stayed largely
consistent. So we are working with the Gloucestershire
Clinical Commissioning Group (CCG)  to improve the
way we provide patients with options for urgent care.
A public awareness campaign was launched by the
CCG ahead of the winter season to help people make
the right choice about where to go for their care.
We are working with a company called Care Home
Selection which helps patients find a care home or
organises packages of care for those who need support
in their own homes. Its experienced advisors work on
our wards directly supporting patients and their families
as they go through the process of finding onward care.
Introducing seven day services
in our hospitals
Patients need the NHS every day. Evidence shows that
nationally, the limited availability of some hospital services
at weekends can have a detrimental impact on outcomes
(the result of their treatment and care) for patients.
In December 2013, Sir Bruce Keogh, National
Medical Director for NHS England, published a
paper outlining ten key standards that describe
the quality of urgent and emergency care that all
patients should expect seven days a week.
They describe, for example, how quickly people admitted to
hospital should be assessed by a consultant, the diagnostic
and scientific services that should always be available
and the process for handovers between clinical teams.
This will be a significant and challenging piece of
work for us locally and will require fundamental
changes to the way we organise our consultants'
work and how we organise our services.
The drive to deliver a consistent quality of care across
the seven day week is incorporated in our strategic plan
for the next five years and our operational plan for the
next two years. During 2015 we will continue to deliver
our plan to move towards achieving the 10 national
standards for seven day services. A pilot in the respiratory
speciality started in October 2014 and is now shaping
the plan for the way seven day services will be delivered
across our hospitals. The pilot in respiratory has improved
the way we provide Board Rounds (reviews of patients
on a ward between doctors, nurses and other relevant
services such as physiotherapy) with consistent attendance
from specialists and has delivered consultant-led ward
rounds every day of the week. We have also improved
the procedures for medical and nurse handovers.
We have shown that small improvements can be achieved
without additional resource through a change in the timing
of events or by shifting priorities, but significant changes
to the way our workforce is employed are required to
meet the standards every day of the week across both
hospitals. We are running a parallel programme in our
Trust to look at our long term workforce requirements
and will publish a ‘people strategy’ in mid-2015.
The roll out to the rest of the hospital started in January
2015. This began with a thorough gap analysis (an
assessment of where we are compared with where we
want to be) against all 10 standards and incremental
improvements are now being made, tailored to the priorities
in each specialty. Where additional resource is required,
cases will be assessed by our Business Development Group.
A county-wide Steering Group, led by Dr Frank Harsent, has
also been set up with membership at senior level from all
providers, including Gloucestershire Clinical Commissioning
Group and social services. A county-wide working
group is also exploring the links between providers.
This work will continue into 2015/16.
17
2.1 | How well have we done in 2014/15?
Fig. 4: Emergency Department 4-hour wait performance 2014/15
Apr
2014
May
2014
Jun
2014
Jul
2014
Aug
2014
Sep
2014
Oct
2014
Nov
2014
Dec
2014
Jan
2015
Feb
2015
Mar
2015
CGH
97.60%
96.88%
97.14%
95.93%
96.99%
97.08%
93.04%
94.90%
85.34%
86.95%
83.35%
93.10%
GRH
91.69%
91.43%
90.09%
89.45%
95.90%
93.54%
93.08%
89.93%
82.77%
80.59%
73.93%
83.31%
Total
93.81%
93.39%
92.64%
91.83%
96.29%
94.87%
93.07%
91.67%
83.65%
82.86%
77.45%
86.77%
Fig. 5: Number of discharges by hour of the day 2014/15
8000
7000
NUMBER OF DISCHARGES
CHARGE
9000
6000
5000
4000
3000
2000
Data
1000
0
0
1
2
3
4
5
6
7
8
9
10
11
12
13
HOUR OF DISCHARGE
14
15
16
17
18
19
20
21
22
23
2.1.1
How well have we done in 2014/15?
Clinical Effectiveness
Reducing violence and aggression
Improve care for patients
At our Trust we do a variety of things to protect NHS
staff from violence and aggression. We have dedicated
security professionals whose role is to ensure the best
use of valuable NHS resources and develop a safer more
secure environment for NHS care. We also have extensive
training on conflict resolution and if a role requires
it, extensive safer handling training for staff dealing
with patients who display challenging behaviour.
with dementia and delirium
Additionally we have a range of support services that can
be accessed by staff if they have been physically assaulted.
In the 2014 National Staff Survey, 17% of our staff
said they had experienced physical violence from
patients, relatives or the public in the last 12 months.
This was slightly less than in 2013 when 18% said
they had experienced violent behaviour, but above
the national average for 2014 which was 14%.
During 2014/15 we took part in the Sign up to Safety
campaign which is a three-year Government initiative
aimed at making the NHS the safest healthcare system in
the world. We pledged to learn from reported incidents
and encourage new staff to look at our procedures to bring
new ideas to our Trust. Part of this commitment is to reduce
clinical condition-induced violence and aggression and a
programme of improvement has now been established.
We also introduced a Sanctions Policy this year, aimed
at supporting staff who have been physically or verbally
abused. The policy will enable us to send letters of warning,
and potentially a ‘responsibilities agreement’ to disruptive
patients or those displaying anti-social behaviour in our
hospitals. This will not be applied to confused patients or
those whose illness is the cause of the disruptive behaviour.
There are around 800,000 people living with dementia
in the UK, costing the economy £23billion a year. By
2040, the number of people affected is expected
to double – and the costs are likely to treble. In
our hospitals, one in four patients may experience
cognitive impairment (problems with memory and
processing thoughts) and around 180 patients with a
diagnosis of dementia are discharged every month.
Early diagnosis is important for a person with
dementia and their carers as it enables them to
understand the condition, access support and the
appropriate treatment to help manage symptoms
and gives the person time to plan for the future.
Delirium is caused by a range of factors and early
recognition is key. Unlike dementia, delirium is
curable, but left undetected it can become a lifethreatening condition. Delirium is defined as a rapid
change in a person’s condition and behaviour, which
is not normal for them. A person with delirium may
become confused, agitated or restless and they
may experience hallucinations or delusions.
Our CQUIN  targets this year were the following:
\\
Case finding 1: to ensure that 90% of patients over
the age of 75, admitted as an emergency are clinically
assessed to identify if they have symptoms which
indicate a loss of memory or some degree of confusion
\\
Case finding 2: to ensure that 90% of these
patients are assessed and investigated further.
\\
Case finding 3: to ensure that 90% of these
patients are referred as appropriate.
\\
To improve the clinical leadership for improving
the care of patients with dementia and delirium
19
2.1 | How well have we done in 2014/15?
Fig. 6: Dementia monthly case finding performance 2014/15
91
90
Target
89
Compliance
88
87
PERCENTAGE
ANDLING
86
85
84
83
82
\\
To explore new ways of capturing feedback
on our services directly from carers and
relatives of patients with dementia.
During 2014/15 we have not met the target
for the assessment of patients each month
(see Figure 6), but we have achieved 100%
compliance for investigations and referrals.
To increase the involvement of senior clinical leaders
in our dementia improvement work, a Trauma &
Orthopaedic Consultant has now joined our Dementia
Steering Group meetings. Many of our patients with
dementia are treated by staff who work in the specialty
of trauma and orthopaedics, as fractures caused by falls
are common in frail, older patients. So it is important
that staff in these areas are skilled in dementia and
delirium assessments and manage their care. We have
introduced a new Trigger Tool which provides the
care team with a checklist of actions to take when
looking after a patient with symptoms of delirium.
To help find new ways of gathering feedback from
patients with dementia, we are one of only two trusts
working with the charity Age UK on a national research
project which involves actively listening and learning from
patients on our wards. The pilot phase, which we expect
to take place during 2015, will see trained volunteers
visiting older or vulnerable patients on four hospital
wards to spend time talking with them and listening, to
understand what we can learn that will help us improve.
MAR-15
FEB-15
JAN-15
DEC-14
NOV-14
OCT-14
SEP-14
AUG-14
JUL-14
JUN-14
MAY-14
0
APR-14
81
To support patients with delirium, and the staff who
manage their care, we have introduced a new Trigger Tool
which provides nurses with a list of key actions to take
when looking after a patient diagnosed with delirium. This
has been supported by an e-learning package and targeted
awareness campaigns led by the Dementia Champions who
work on each of our hospital wards and in some other
departments such as physiotherapy and outpatients.
As part of our drive to make the ward environment
more dementia-friendly, our General and Old Age
Medicine wards have this year had 70 dementiafriendly clocks installed. The large clocks, which display
the date as well as the time, are expected to help
Dementia clock
20
2.1 | How well have we done in 2014/15?
orientate patients who are cognitively-impaired.
breathing, primarily due to the narrowing of their airways.
Reducing the incidence
Patients with COPD often attend hospital regularly, so
standardising and improving the way that these patients
are treated will benefit both the patient’s experience
and reduce pressure on our services. Each month around
100 patients with COPD are admitted to our hospitals.
of Acute Kidney Injury
Acute Kidney Injury (AKI) is a sudden loss of kidney
function and is strongly linked to high mortality rates
and an increased length of stay. In a hospital there are a
number of reasons why a patient may develop an AKI, for
example through infection or as a result of dehydration.
This year we had a target of treating 85% of all
patients highlighted by our pathology team as
at risk of AKI based on test results, with a care
bundle  within 24 hours. This bundle includes:
\\
a review by a senior clinician
\\
a fluid balance assessment for the patient
\\
a review of medication to ensure any drugs
prescribed do not adversely affect the kidneys
\\
a repeat creatinine test (a blood test which
measures how well the kidneys are working).
The team has introduced a care bundle  with the support
of the emergency consultants, junior doctors, specialist
nurses and physiotherapists. The care bundle improves
the reliability of key clinical interventions occurring at
the right time for every patient. The CQUIN  target
during 2014/15 was to ensure that 80% of patients,
both at individual hospitals and as a Trust, received
the COPD care bundle by the end of Quarter 4.
During 2014/15 patients were audited to assess whether
they were receiving key treatments as developed by the
British Thoracic Society. These treatments are as follows:
Meeting this target, which increased from 75% at the
end of 2013/14, has been a challenge (Figure 7). During
2014/15, our performance against the target for improving
the management of patients with AKI, by use of the
AKI care bundle, was affected by the acute care units
which were experiencing an exceptionally busy year.
As with the Sepsis Six initiative, our focus has now
shifted to identifying patients who are potentially at
risk of AKI, much earlier - before they come to hospital.
We have been working with our local GPs and other
primary care providers, giving clinical advice and providing
training to help them put in place AKI risk assessments,
or scoring systems, to detect the early warning signs.
While we acknowledge that we have not consistently met
the target that was set, we remain confident that we are
at the forefront of quality in healthcare when it comes to
the detection and diagnosis of AKI. A national algorithm
(a step-by-step method of making a diagnosis) was agreed
during 2014 to make sure that the care of patients with
AKI was consistent across the NHS. We have been using
this methodology for some time in our hospitals.
Improving the care for patients with
Chronic Obstructive Pulmonary Disease
Chronic Obstructive Pulmonary Disease (or COPD) is the
name for a collection of lung diseases including chronic
bronchitis, emphysema and chronic obstructive airways
disease. COPD is one of the most common respiratory
diseases in the UK, affecting more than three million
people nationwide. People with COPD have difficulties

\\
oxygen should be administered within one hour
of admission (if required) and a target oxygen
saturation range prescribed during that admission
\\
if oxygen levels are less than or equal to 94%,
Arterial Blood Gas (ABG) tests should be
performed. These measure the levels of oxygen
and carbon dioxide in the blood and indicate
how well a patient’s lungs are functioning
\\
nebulisers, steroids and antibiotics should be
administered within four hours of admission
(if indicated as appropriate by a doctor).
This programme of work has been led by two consultants:
Dr Andrew White (a respiratory specialist) and Dr Helen
Mansfield (a specialist in emergency care). Their involvement
and leadership of this project has meant that we have
been able to engage effectively with clinical staff and
significantly exceed our target, as shown in Figure 8.
Reducing variation
Variation in the way we are treated by healthcare
professionals is not always considered to be a bad thing. We
are all individuals with individual needs and there are many
good reasons why one person’s treatment will need to be
different from another patient with a similar condition.
These are considered to be ‘natural variations’, and are
an inevitable and positive feature of healthcare systems.
However some variations in the way we work are less
desirable and can affect our ability to run services
efficiently and safely. Some examples of these might be:
\\
the way we schedule services
\\
the working hours of staff and how leave is planned
\\
the order in which we see or treat patients
0
MAR-15
FEB-15
JAN-15
DEC-14
NOV-14
OCT-14
SEP-14
AUG-14
JUL-14
JUN-14
MAY-14
APR-14
MAR-14
FEB-14
JAN-14
DEC-13
MAR-15
FEB-15
JAN-15
DEC-14
NOV-14
OCT-14
SEP-14
AUG-14
JUL-14
JUN-14
MAY-14
APR-14
MAR-14
FEB-14
JAN-14
DEC-13
NOV-13
OCT-13
0
NOV-13
% COMPLIANCE
COPD
% COMPLIANCE
AKI
OCT-13
2.1 | How well have we done in 2014/15?
21
Fig. 7: Compliance with the AKI bundle 2014/15
100
90
80
70
Target
60
Compliance
50
40
30
20
10
Fig. 8: Compliance with the COPD bundle 2014/15
90
80
70
Compliance
Target
60
50
40
30
20
10
22
2.1 | How well have we done in 2014/15?
\\
the way patients are managed and drugs
are prescribed eg. not using evidencebased agreed pathways or protocols
\\
standardisation of hip and knee replacements.
A lot of work has been done to help NHS organisations
understand and reduce these kinds of variations.
For our organisation, the move from paper notes
towards an electronic health record for every patient
will significantly reduce variation in their care. Our
SmartCare project will bring mobile digital technology
to our wards, enabling doctors to make decisions and
access information about patients at their bedside.
By using these devices, clinicians will be able to make
their decisions within the parameters of agreed pathways
and protocols, while still providing enough flexibility in
the system to make independent clinical judgements
where appropriate. These devices have the added benefit
of providing us with a clear audit trail for the treatment
of each individual patient. If there are significant or
concerning variations in the clinical outcomes (results
of treatment and care) of a particular group of patients
then these can be quickly and easily investigated via
the data gathered by the new SmartCare system. The
implementation of this project has been the primary
focus for reducing variations of care in 2014/15.
In February 2015 we signed a contract with a
company called InterSystems to provide us with
their TrakCare unified electronic health record.
The new system, the purchase of which was supported by
£10million of Department of Health funding, will support
clinical decisions, lead to better prescribing of drugs and
improve staff and patient communications. The project
planning is now well underway and we expect to ‘go live’
with the first phase of the system by the end of 2015
with a further two years of phased roll-out as we begin
to use the additional clinical systems with TrakCare.
23
2.1 | How well have we done in 2014/15?
Next section:
How well have we done in 2014/15?
Patient Experience
2.1.1
How well have we done in 2014/15?
Patient Experience
The friends and family test
The NHS Friends & Family Test provides an important
opportunity for our patients to give us feedback on
our services, their care and treatment. It is a national
scheme which was introduced in 2013 and asks patients
whether they would recommend the hospital ward,
A&E department or maternity services to their friends
and family if they needed similar care or treatment.
This means every patient in these wards and departments
is able to give quick feedback on the quality of care they
receive, giving our hospitals a better understanding of
the needs of our patients and enabling improvements.
Our CQUIN  targets for this year were:
\\
to implement the Staff Friends & Family Test
\\
to introduce the Friends & Family Test to outpatient
areas (a pilot site by the end of Q2 and in all
outpatient and day case areas by the end of Q4)
\\
to increase the response rate (from 15% to 20% of all
patients attending the Emergency Department and from
15% to 30% of all adult inpatients by the end of Q4)
\\
to show how we have learned from
the feedback received.
In the first quarter of the year we asked all our staff
the Friends & Family Test questions, which are:
\\
Would you recommend our Trust as a
place of work to friends and family?
\\
Would you recommend our services
to your friends and family?
In Q2 and Q4 we repeated the survey, but this time
targeting medical staff who have historically been less
engaged in giving their feedback during surveys. A total of
102 doctors responded, a response rate of 14%. 57% of
those who responded said they would recommend us as
a place to work and 76% would recommend our services
to their friends and family. In Q3 we asked all staff these
questions as part of the National Staff Survey, which 54%
of our staff responded to. This year 55% of respondents
said they would agree or strongly agree that they would
recommend us as a place to work (the national average
of all trusts was 55%), and 62% said they would agree
or strongly agree that they would recommend us as a
place of care (national average of all trusts was 63%).
Introducing the Friends & Family Test to outpatient areas
of our hospital has been challenging due to the high
turnover of patients which visit them and the length of
time they spend there. By the end of March 2015 we had
successfully implemented the Friends & Family Test to all
outpatient and day case areas. We will continue to explore
new ways of gathering this feedback in the coming year.
In our paediatric department we will be asking the Friends
& Family Test via an app  on a mobile device such as an
iPad to help us better engage with our younger patients.
By the end of Q4 we had received 13,515 responses
from adult inpatients (in 2013/14 we received 9972)
with a response rate of 39.7% (see Figure 9). The
number of positive responses per month ie those
patients who reported that they were extremely likely
or likely to recommend was an average of 95%.
During the same period in our Emergency Department
we received responses from 10,803 patients (in
2013/14 we received 7,186) with a response rate of
27.2%. The number of positive responses ranged
from 88-93% during the year (Figure 10).
Response rates have improved throughout the
year and we have met all our CQUIN targets
relating to the Friends & Family Test.
The full results of the Friends & Family Test are published
on the NHS Choices and NHS England website and
are available on our own website. We also share the
25
2.1 | How well have we done in 2014/15?
Fig. 9: Inpatient response rate to Friends and Family Test 2014/15
40
35
2013/14
30
2014/15
25
PERCENTAGE
20
15
10
5
MAR
FEB
JAN
DEC
NOV
OCT
SEP
AUG
JUL
JUN
MAY
APR
0
Fig. 10: Response rate for Friends and Family Test in the Emergency Department 2014/15
30
25
20
2014/15
10
5
MAR
FEB
JAN
DEC
NOV
OCT
SEP
AUG
JUL
JUN
MAY
0
APR
PERCENTAGE
ED FFT
2013/14
15
26
2.1 | How well have we done in 2014/15?
ward-level results with each ward, displaying the data
and any narrative feedback in a simple poster.
Learning from feedback
We believe that it is not only important to receive feedback
from patients, but also to hear what our carers, visitors
and staff are telling us and to respond positively to those
comments, making improvements where they are needed.
We also believe we should share the lessons we
have learned with the public so that people can
see the value in sharing their feedback with us
and understand that their comments can and do
lead to real improvements in our hospitals.
As we have already outlined above, the feedback and
results we receive from the Friends and Family Test are
shared with each ward in the form of a poster. The ward
sister is also asked to complete a Learning Log which asks
them to highlight at least two things they have learned
from the feedback received, including any changes made as
a result. These logs are shared with the patient experience
team and used by the wards to monitor any common
themes that arise. Learning from both complaints, concerns
and the Friends & Family Test is published each month in a
Lesson Plans feature in our staff magazine which is shared
on our website. The same actions are also shared in the
Chief Executive's report to the Board meeting each month.
We receive feedback from our patients in many different
ways. Patients can share their comments, concerns,
complaints or compliments with staff, with our PALS or
complaints teams, via the Friends & Family Test or online
via websites like NHS Choices or Patient Opinion, or social
media sites such as Twitter or Facebook. Locally, the
views of patients are also represented by Healthwatch
Gloucestershire . Our PALS team help large numbers of
patients and families to address and resolve their concerns
quickly and professionally – they have dealt with 1,531
concerns so far this year (end of Quarter 4). Our Head of
Patient Experience and the Director of Clinical Strategy
meet with Healthwatch each quarter to discuss any issues
or concerns they may have on behalf of our patients. All
feedback received by Healthwatch from our patients is
then passed on to the relevant division in our hospitals
so that the comments can be shared and acted upon.
Patients themselves have also been invited to share
their experiences directly with our Board, providing real
insight into the personal experiences of our patients.
These patients have raised a broad range of issues
including the care of patients with sepsis, treating people
who self-harm and the experience of young carers.
Face to face meetings with members of staff are also often
offered to patients who are not happy with their care to
help resolve their concerns with the teams involved. This
can help give the person complaining a greater insight into
why something may have happened and helps staff learn
how their actions can affect the experience of patients.
To make sure that the complaints process is as good
as it can be, we have also conducted a peer review of
our complaints service against nationally regarded best
practice Patient Association guidelines. Overall the results
of this review were positive and we identified some areas
for improvement. We discovered, for example, that we
need to do better at providing more information about
the actions being taken in response to their complaint.
Everyone who has made a complaint is now sent a
survey seeking their views on the process of complaining
and their experiences. In February 2015, the Patients
Association provided training on complaints management
to senior clinical and non-clinical managers. We work
closely with SEAP – a local complaints advocacy
support organisation, hosted by Healthwatch
Gloucestershire. We hope that this will improve the
process of complaining for both our patients and for
us in learning from the experiences that are shared.
Involving patients in improving services
We believe that it is often those closest to the
process of providing healthcare who are best placed
to give useful feedback on the way services work
and on how they can be improved in the future.
Our patients experience our services first hand;
they have a unique, highly relevant perspective
on what works and what doesn't. Their input into
designing services can therefore be invaluable.
Sometimes, seeing services from the patients’
point of view opens up real opportunities for
improvement that may not have been considered
before. This may include changes that make life
easier for staff and patients, whilst reducing
delays or other inefficiencies at the same time.
We are continually looking at how we can better
design our services so they meet the needs of
our population within the resources available.
Patients, or 'users' of our services, as well as some
Foundation Trust Members, are actively involved in many
projects aimed at improving our hospital services. For
example, we have lay members of our Cancer Patient
Group, Maternity Liaison Group, Organ Donation
Group and Venous Thrombo-Embolism Group. Their
views help us make sure that services are developed in
27
2.1 | How well have we done in 2014/15?
response to the needs of the people who use them.
We are also exploring other, evidence-based approaches
to involving patients in the development and design of
services. An example of this is a project to improve stroke
services, which is currently in its early stages. Stroke
patients, and their carers and staff, will be contributing to a
unique film which will share their experiences and consider
how they can be used to develop the service further.
A shadowing technique is also being used to find out
how we can improve the care and treatment of our
elective orthopaedic patients. A member of the project
team will follow between 10 and 12 patients as they go
on their journey from initial consultation through surgery
and eventual discharge from hospital care to see what
we can learn from the experiences they have with us.
These two methods of learning have been used in other
healthcare organisations and are proven to have success
in developing efficient,high quality services for patients.
Delivering compassionate care
We know that it is the commitment, professionalism
and dedication of our staff that can make the
greatest difference in providing high quality services
and care for patients and their families.
In April 2013 NHS England set out a 'Compassion
in Practice' strategy to transform care in all
support settings. Part of this strategy is to ensure
that hospital staff demonstrate the 6Cs in their
practice and daily working lives. The 6Cs are:
This year our staff supported the #hellomynameis campaign
\\ care: defines us and our work. People receiving
care expect it to be right for them consistently
throughout every stage of their life
\\ compassion: is how care is given with
empathy, respect and dignity
\\ competence: means all those in caring roles must
have the ability to understand an individual's health
and social needs and the expertise, clinical and
technical knowledge to deliver effective care and
treatments based on research and evidence
\\ communication: is central to successful caring
relationships and to effective team working.
Listening is as important as what we say and do
and essential for 'no decision without me.'
a cornerstone of what we do. We need to build
on our commitment and improve the care and
experience of our patients to take action to make
this vision and strategy a reality for all and meet
the health and social care challenges ahead.
Meeting these six core statements is an objective
of our Nursing and Midwifery Strategy and informs
our approach to recruitment and education.
Our matrons (senior nursing staff) work a clinical shift
on a ward every second Tuesday so they are available
to lead and mentor junior nurses, can monitor the
standard of care being delivered, and provide a visible
and reassuring senior nursing presence, available to
answer any questions that patients may have.
\\ courage: enables us to do the right thing for the
people we care for, to speak up when we have
concerns and to have the personal strength and vision
to innovate and to embrace new ways of working
\\
commitment: to our patients and population is
This year we have actively joined the #hellomynameis
campaign - a social media-led initiative that aims to remind
staff of the importance of making an introduction to
patients when delivering care. The national campaign was
28
2.1 | How well have we done in 2014/15?
launched by Dr Kate Granger, a terminally-ill cancer patient,
who noticed during her treatment with another trust that
many staff forgot to introduce themselves before providing
care. Dr Granger believes that introducing yourself is more
than just knowing someone's name, but is about making
a human connection with your patient - the beginning
of a therapeutic relationship and building trust. Our
staff have enthusiastically signed up to the campaign..
Providing compassionate care to our patients runs
through many of the projects and initiatives that we have
reported on in this document, from learning from the
experience of our patients to involving patients and carers
in the design and development of our services. It is a
fundamental principle for the delivery of all healthcare, not
just for nurses, and will continue to be a priority for us.
Reducing cancer waiting times
More than one person in three will develop cancer at
some time in their lives and one in four will die of cancer.
More than 250,000 people in England are diagnosed
with cancer every year and around 130,000 die from it.
Early detection and treatment are crucial if patients
are to have the best possible outcomes and the
growing public awareness and screening programmes
mean that survival rates and patients’ experience
of care are improving at a national level.
The impact of successful public awareness campaigns
emphasising the importance of early detection has
also been felt locally in our hospitals. Our oncology
service receives around 1,200 referrals a month, yet
only 10% of these patients are likely to be diagnosed
with cancer. Referrals of patients with suspected
cancer continue to increase month on month.
Currently all patients referred with suspected cancer
by their GP have a maximum wait of two weeks to
see a specialist consultant. Cancer patients should
also wait no more than 31 days from the decision to
treat to the start of their first treatment. Both of these
two targets are consistently met across our Trust.
However, 85% of patients should also wait a maximum of
62 days from their urgent GP referral to the start of their
treatment. This national standard also includes all patients
referred from NHS cancer screening programmes (breast,
cervical and bowel) and all patients whose consultants
suspect they may have cancer. While we achieved this
target for most of the summer months during 2014/15, the
Q3 and Q4 proved challenging (see Figure 11). Of the 120130 patients we see a month on the 62 day target pathway,
around four or five of these are not meeting the target.
The key issue remains the impact of increased
referrals. We have eliminated delays in radiology
(scans), recruited additional staff in histopathology
(laboratories), increased the capacity in our theatres
and standardised working practices across both
hospitals – the lack of which had contributed for
our failure to meet the target during 2014/15.
In the year ahead we will be looking at specific pathways
(the way patients move through the hospital process from
diagnosis through to treatment and discharge) to see if
there are more efficient ways of running the service. In
particular we will be looking at pathways for patients
with urological, upper and lower gastro-intestinal and
lung cancers. This could include, for example, offering
one-stop clinics where patients receive tests and see a
specialist during one single appointment. We are also
looking at how we manage follow up appointments for
cancer patients, reviewing options for offering open rather
than fixed appointments, for example, so that patients
can request specialist support when they need it.
This year our Endoscopy Department at Cheltenham
General Hospital achieved JAG (Joint Advisory Group)
accreditation, the ‘gold standard’ for endoscopy units.
This means we can continue to provide bowel cancer
screening for our patients, helping with early detection of
cancer and increasing the chances of survival. It has also
increased our overall capacity for providing diagnostic tests.
29
2.1 | How well have we done in 2014/15?
Fig. 11: Performance against 62 day cancer target 2014/15
100
Compliance
95
90
Target
80
75
MAR-15
FEB-15
JAN-15
DEC-14
NOV-14
OCT-14
SEP-14
AUG-14
JUL-14
JUN-14
MAY-14
APR-14
MAR-14
FEB-14
JAN-14
DEC-13
NOV-13
OCT-13
SEP-13
AUG-13
JUL-13
JUN-13
0
MAY-13
70
APR-13
% MEETING TARGETS
85
Next section:
What are our priorities for 2015/16?
2.1.2
What are our priorities for 2015/16?
The table opposite provides an overview of our
priorities for 2015/16. The table gives you an at-aglance view of the work to be undertaken in the
year ahead and which of our stakeholder groups
highlighted it as an issue to be addressed.
31
2.2 | What are our priorities for 2015/16?
Priorities for improving quality in 2015/16
Priorities
Incomplete
from last year
National priority
for 2014/15
Issue for
commissioners
/ CQUIN
Issue for
HCCOSC


Issue for
Healthwatch
Issue identified
internally inc.
govenors
1. Safety
Pressure ulcers

Reduce the risk of VTE
Improving patient flow



Improving handover






Reducing missed fractures



2. Clinical Effectiveness
Dementia and delirium




Acute Kidney Injury




Improving diabetic footcare



Improving care of patients
requiring emergency abdominal
surgery





Improving care for
fragility fractures
Improving the
management of sepsis






3. Patient Experience
Improving transition from child to
adult care
Learning from users

Improving patient information
Living with and beyond cancer










2.1.2
What are our priorities for 2015/16?
Safety
Reducing pressure ulcers
During 2015/16 we will introduce a national initiative
on our wards as part of the Stop the Pressure
campaign, known as SSKIN. This stands for:
\\
surface: make sure your patients have the right support
\\
skin inspection: early inspection means early detection.
Show patients and carers what to look for
\\
keep: your patients moving
\\
incontinence/moisture: your patients
need to be clean and dry
\\
nutrition/hydration: help patients have
the right diet and plenty of fluids
To help us embed this method of pressure ulcer prevention
on all our wards, we have introduced a ‘care bundle’
to support staff. If a patient scores 10 or more on the
Waterlow scoring system  which indicates that they are
at risk of developing an ulcer, then staff can use the
bundle to help manage their care. The bundle includes a
care plan, a turn chart to monitor the number of times
the patient is turned and a wound chart to monitor
the size and development of any ulcers detected.
During 2015/16 we will continue to support pressure
ulcer awareness campaigns through events and training.
Our action plan will again focus on the education
of staff and the purchase of new equipment.
Reduce the risk of Venous
Thromboembolism (VTE)
Venous thromboembolism (VTE) is the collective
term for Deep Vein Thrombosis (DVT) and Pulmonary
Embolism (PE). DVT is a blood clot in one of the deep
veins in the body. It can cause pain and swelling and
may lead to complications such as PE. This is when a
piece of blood clot breaks off into the bloodstream
and blocks one of the blood vessels in the lungs.
Each year more than 25,000 people in England
die from VTE contracted in hospitals. This is more
than the combined total deaths from breast cancer,
AIDS and traffic accidents and more than 25 times
the number who die nationally from MRSA.
Reducing the risk of VTE was a target for us in
2014/15 when we were expected to risk assess
95% of all patients with a clinical condition which
could lead to a VTE, which accounted for almost
every patient admitted to our hospitals.
During 2014/15 our average monthly
score against this target was 93%.
During 2015/16 we will be putting together
an action plan to make sure that awareness
of the life-saving potential of the risk
assessments is maintained among staff.
Improving flow through emergency
care, outpatients and discharge
As explained in section 2.1.1 we have experienced real
pressures in our hospitals during 2014/15, both in our
Emergency Departments  and in being able to discharge
patients when they are ready to leave. Alleviating some
of this pressure will be a key priority for us during the
year ahead. We will continue to work with our partners
in the community to reiterate the importance of
providing timely care home place, community hospital
bed or other suitable onward care for patients once
33
2.2 | What are our priorities for 2015/16?
they are medically fit and ready to leave our hospitals.
This work will focus on two key areas:
\\
managing emergency admissions
\\
improving the discharge of patients.
While reducing delays and improving the rate at which
patients move through our hospitals is important, it is
also vital to ensure that the experience of the patients
involved remains a central focus. Planning ahead is
important for patients and their families or carers, so
we want to make sure that everyone involved knows
in advance when we would expect a patient to be
discharged from hospital. In 2014 we introduced a new
leaflet to help staff talk to patients about the discharge
process, when they can expect to leave our care and to
help them understand what lies ahead. This emphasis
on maintaining a high standard and quality of care
during busy periods and making sure patients are clear
about their treatment, eventual discharge and ongoing
support where needed, will be a focus the coming year.
In the year ahead we will also be looking again at
our Length of Stay programme; offering earlier ward
rounds, getting clinical decisions about discharges
made earlier in the day and being clear about how
we can overcome issues when they arise.
We will be introducing the SAFER flow bundle, a
set of actions which combined, should improve the
flow of patients through our hospitals and prevent
unnecessary waits. If we routinely carry out these
actions, we will improve the experience of patients
when they are admitted to hospital and meet our
four hour waiting target in A&E. The SAFER flow
bundle will be a CQUIN goal for us during 2014/15.
Our outpatient departments are also always busy, with
thousands of patients coming through their doors each
month. The rising demand on our services means that
currently there are around 14,000 patients waiting
longer than they should do in our clinics. One third of
these are in the ophthalmology department, but we also
have long waits for cardiology, respiratory, neurology,
rheumatology and paediatric outpatient clinics.
Each of these specialty areas is looking at how best they
can organise their outpatient clinics to meet the demand on
this service, exploring options such as automated checkin, text reminders and displaying prominent information
about current waiting times in the department.
Improving handover
In our hospitals, junior medical staff work in a shift
pattern, much like nurses. Because nurses have always
traditionally worked in shifts, they are well used to
sitting down together as one group prepares to leave
and another comes on duty. The reason for this meeting
is to allow the team who has been on duty to inform
the new staff about the condition of the patients they
will be responsible for. Each patient is presented and
their healthcare discussed. Tests that are due to be
carried out will be mentioned and those who have been
referred to different teams would be highlighted.
This same process is now required between medical
staff to help us achieve seven day working. The
standard for seven day working states that handovers
must be 'led by a competent senior decision
maker and take place at a designated time and
place, with multi-professional participation from
the relevant in-coming and out-going shifts.'
As part of the seven day services project, a pilot was held
in the respiratory department at both Gloucestershire
Royal and Cheltenham General Hospitals. You can
read more about this on p16. We looked in detail
about how the handover process worked and how
we could meet the seven day handover standard.
We will continue to look at the way that medical
and surgical handovers work in our hospitals in the
coming year, to work towards the seven day standard
across all specialties. We will also be looking at how
we can improve the way we hand over to other
organisations once a patient has left our care as
this is an essential part of discharge planning.
Reducing missed fractures
As a Trust, we have joined the Sign Up To Safety campaign
- publicly stating our commitment to making our hospitals
safer. The Sign Up To Safety national campaign is designed
to help realise the ambition of making the NHS the safest
healthcare system in the world by creating a system
devoted to continuous learning and improvement. Sign Up
To Safety aims to deliver harm free care for every patient,
every time, everywhere. It champions openness and honesty
and supports everyone to improve the safety of patients.
You can read more about what we plan to do on our
website under 'About Us.' Our Safety Improvement
Plan was submitted to the NHS Litigation Authority
with a bid for funding to help deliver key objectives. In
2015/16 we have put forward our bid to improve two
key areas based on analysis of our claims for litigation
and discussion with our clinicians, such as doctors and
nurses. One of these is to reduce the number of missed
fractures (broken bones) in our Emergency Department.
We aim to do this by improving the technology used to
identify fractures and to create greater availability of senior
clinicians so help make sure the right diagnosis is made.
2.1.2
What are our priorities for 2015/16?
Clinical Effectiveness
Improving care for patients
with dementia and delirium
Improving the way we care and treat these
vulnerable groups of patients will continue
to be a priority for us again this year.
This remains a national CQUIN  with targets
relating to finding, assessing, investigating and
referring new cases of dementia in patients admitted
as an emergency to our Acute Care Units.
Delirium is linked to dementia and frailty,
and early recognition and management
can greatly improve outcomes.
Objectives for us in support of our patients with
symptoms suggestive of delirium, include the roll out of
a delirium screening and assessment tool to all General
and Old Age Medicine wards, that includes guidance
on treatment and management. This is also supported
by staff awareness and education campaigns.
Improving the management of
patients with Acute Kidney Injury
As described on p20, Acute Kidney Injury (AKI) is a sudden
decline in kidney function. In England over half a million
people sustain AKI every year, with AKI affecting 5-15%
of all hospital admissions. As well as being common,
AKI is harmful and often preventable and is therefore a
major patient safety challenge for healthcare providers.
During 2015/16 the national CQUIN goal will be to
improve the follow up and recovery for patients who
have sustained AKI, reducing the risks of them being
re-admitted to hospital, re-establishing medication for
other long-term conditions and improving the follow up
of episodes of AKI which is associated with increased
risk of cardiovascular (heart) disease in the long term.
Improving diabetic footcare
Diabetes can lead to a number of complications
including heart disease, kidney disease, retinopathy
(eye problems), problems with peripheral circulation
(peripheral vascular disease) and neuropathy (a
nerve disorder). Peripheral vascular disease and
neuropathy can lead to the development of ulcers
in the feet which, because of reduced blood flow,
heal poorly and can lead to surgical amputations.
In Gloucestershire the number of amputations we
perform on patients with diabetes is above the national
average. A National Diabetes Audit carried out in
2012/13 showed that in Gloucestershire we carried
out 172 minor amputations on diabetic patients.
In order to address this, we have been working with our
partners in the Gloucestershire Clinical Commissioning
Group  to identify ways we can improve the care for
patients with diabetes. We aim to ensure that:
\\
patients with diabetes are regularly screened at least
annually for foot problems eg ulcers by their GP
\\
patients who are identified through the screening
process as being at a high risk of developing foot ulcers
are referred to specialist services within primary care
\\
patients who have an established issue
(such as an ulcer) are rapidly referred to
our hospital service for treatment
35
2.2 | What are our priorities for 2015/16?
\\
all patients with diabetes who attend our Emergency
Departments (A&E) and need admission, irrespective
of underlying admission diagnosis, have their feet
checked by clinicians and are quickly referred to
our specialist team if any ulcers are identified.
Improving foot care for patients with diabetes
will be a CQUIN for us this year, although
the targets have yet to be agreed.
Improving the management of patients
requiring emergency laparotomy
Emergency laparotomy is a name used to describe a number
of different surgical procedures performed on emergency
patients with severe problems affecting their abdomen.
There are approximately 80,000 emergency laparotomy
procedures every year in the UK, but the procedure is
risky, with 14% of patients dying within 30 days. For
those over the age of 80, this can increase to 25%.
A project to develop a new care pathway has been
developed nationally, and during 2015/16 our Trust,
alongside several others, will be implementing
the care bundle they have developed. The care
bundle  aims to standardise the care received by
all patients undergoing emergency laparotomy,
with the aim of improving patient outcomes.
To help us identify how we can improve, we have asked
the Royal College of Surgeons to conduct a review of
our hip fracture service. This will take place in June 2015.
This year we also intend to look at how we can better
organise the trauma service across our hospitals to ensure
we can provide high quality care for these patients across
the seven day week. We need to make sure that patients
with fragility fractures are properly assessed by a senior
clinician before and after they have surgery and that this
happens consistently, regardless of the day of the week.
Improving the management of sepsis
Improving the care for patients with the early signs of sepsis
was a priority for us in 2014/15 and more information
on the impact of sepsis for patients is included on p13.
For 2015/16, improving the management of sepsis
has been identified as a national CQUIN .
The CQUIN  will focus on standardising the early care of
patients with sepsis in the Emergency Department (A&E)
and acute care units. We expect to continue our focus on
promoting the FAB 60 campaign, as explained on p13.
The pathway has five key steps:
\\
early assessment and resuscitation
from a senior clinician;
\\
the administration of antibiotics to those
patients who show signs of sepsis
\\
prompt diagnosis and early surgery
\\
goal-directed fluid therapy in theatres
and continued to intensive care unit
\\
post-operative intensive care for all.
Improving care for fragility fractures
Fragility fractures are fractures (broken bones) that
result from a fall from standing height or less. They
often affect frail, elderly patients, and are an increasing
cause of admissions to hospitals nationally. Each
year the UK spends around £2 billion treating and
caring for patients with hip fractures. Hip fractures
are debilitating, restrict the patient's independence
and the mortality associated with them is high.
In our hospitals, our own mortality rate indicators and the
National Hip Fracture Database have alerted us to a higher
than expected mortality rate in patients with hip fractures.
In addition, these patients with fragility fractures are not
receiving their operations as quickly as they should.
Next section:
What are our priorities for 2015/16?
Patient Experience
2.1.2
What are our priorities for 2015/16?
Patient Experience
Improving care in transition
These three projects are:
from children’s to adult services
\\
Listening and learning: we are working with Age UK
on a national research project which involves actively
listening and learning from patients on our wards, to
understand what we can learn to help us improve
\\
Shadowing: this technique is currently being
used to see how we can improve the care
and treatment of orthopaedic patients
\\
Experience-based co-design: another evidencebased approach to learning from our patients, we
are currently seeing how involving both staff and
patients can help us improve stroke services.
There is strong evidence to suggest that nationally,
the transition from children's to adult health
care is patchy with poor engagement and poor
outcomes in terms of mortality and morbidity.
The process of moving from child to adult services
should be planned and centred around the young
person's physical and mental health needs.
Transition to adult services is high on the national
and regional agenda, with a nationally appointed
NHS England Lead for Transition and with the South
West Children and Maternity Strategic Clinical
Network prioritising transition for improvement.
We will be identifying actions to help us improve
the way children and young people transition to
adult care in our hospitals in the year ahead, starting
with services for young people with epilepsy.
These projects started in 2014/15 and
will continue in the year ahead.
Improving patient information
Good patient information is important because it can:
\\
help to ensure that patients arrive on time and are
prepared for their treatment, procedure or appointment
\\
give patients confidence, improving
their overall experience
\\
remind them of what they have already
been told (in case they have forgotten)
\\
provide them with accurate information
\\
involve patients and carers in their care
Learning from users
In 2015/16 we will be taking forward three
new projects to tackle three main issues:
\\
communication: improving the way
we communicate with patients
\\
patients' needs: understanding how we can
meet the expectations of our patients
\\
working together: collaborating on the
development of our services using the
experiences of patients and staff
It is important that the information we provide
patients and their families with is accurate, up to
date, well presented and easy to understand.
In our hospitals we have more than 1,000 leaflets
and we know that many are not up to date. To put
this right, we have formed a new strategic group
37
2.2 | What are our priorities for 2015/16?
which is responsible for reviewing all the leaflets on
our system and over-seeing their redevelopment.
We want to make sure that printed leaflets are
in black and white only, making them easier to
read and cheaper to print. We also need to make
sure the leaflets are easy to read online.
We expect this work to take between 12 to 18 months
to complete but once finished, will be a significant
improvement for patients and their families.
Living with and beyond cancer
A cancer diagnosis is a life changing event and every
person will have their individual needs for care and
support, and their own personal experience. The
Gloucestershire Living With & Beyond Cancer Programme
aims to create a sustainable and joined up change to
help people to live well with and beyond cancer.
The programme is a two year partnership between NHS
England and Macmillan Cancer Support and will focus on:
\\
ensuring all cancer patients have access to holistic
needs assessment, treatment summary, cancer
care review and a patient education and support
event, known as 'the recovery package'
\\
developing and commissioning risk stratified
pathways of post treatment management
\\
promoting physical activity
\\
understanding and commissioning for improved
management of the consequences of treatment.
What this means for our cancer services and
patients is yet to be determined, but has been
identified as a quality priority for 2015/16.
Next section:
Statements of assurance
2.2
Statements of assurance
The following section includes responses to a nationally
defined set of statements which will be common
across all Quality Accounts. These statements serve
to offer assurance that our organisation is:
\\
performing to essential standards, such as securing
Care Quality Commission  registration
\\
measuring our clinical processes and performance,
for example through participation in national audits
\\
involved in national projects and initiatives aimed at
improving quality such as recruitment to clinical trials.
Information on the review of services
The purpose of this statement is to ensure we have
considered quality of care across all our services. The
information reviewed by our Quality Committee is
from all clinical areas. Information at individual service
level is considered within our divisional structure and
any issues escalated to the Quality Committee.
During 2014/15 Gloucestershire Hospitals NHS Foundation
Trust provided and/or subcontracted 42 NHS services.
The Trust has reviewed the data available to us on
the quality of care in all of these NHS services.
The income generated by the NHS services reviewed in
2014/15 represents 100% of the total income generated
from the provision of NHS services by Gloucestershire
Hospitals NHS Foundation Trust for 2014/15.
Information on participation
in Clinical Audit
The purpose of this statement is to demonstrate that
we monitor quality in an ongoing, systematic manner.
From 1 April 2014 to 31 March 2015, 34 national
clinical audits and three national confidential
enquiries covered NHS services that we provide.
During that period our Trust participated, or is currently
participating in, 33 (97%) national clinical audits and 3
(100%) national confidential enquiries of the national
clinical audits and national confidential enquiries in
which it was eligible to participate. There was one
audit where our Trust did not participate, for which
there were justifiable reasons (please see Table 1).
The national clinical audits and national confidential
enquires in which our Trust participated, and for
which data collection was completed during 1st
April 2014 – 31st March 2015 are listed in Table 1,
alongside the number of cases submitted to each
audit or enquiry as a percentage of the number of
registered cases required by the terms of that audit or
enquiry or a straight percentage of cases submitted.
The reports of 25 (74%) national clinical audits/
confidential enquiries participated in were reviewed
in 2014 – 2015. Eight reports are still awaited. One is
currently in the data collection phase of the audit. The
actions our Trust intends to take to improve the quality
of healthcare provided are summarised in Table 1.
The reports of over 200 local clinical audits
were reviewed in 2014 - 2015 and we either
have or intend to take the following actions to
improve the quality of healthcare we provide:
\\
an integrated admission to discharge document
was launched in November 2014 as part
39
2.3 | Statements of assurance
of the Improving Patient Choice audit
\\
\\
following an audit of correct paracetamol dosing
in elderly care patients and interventions by
the General Old Age Medicine team there was
an increase in compliance with the adjustment
of paracetamol dosing in patients < 50kg
a reduction in catheter-associated urinary tract
infections and improved compliance with a plan for
trial without catheter was demonstrated following
the introduction of new catheter care plans.
Clinical Audit has been an integral part of our Trust’s
CQUIN  programme during 2014/2015 providing
evidence information for our performance against
VTE, Sepsis, Acute Kidney Injury and Safety
Thermometer objectives. Additionally clinical audit
has also provided information for other national
projects such as the Saving Lives campaign
This high level of participation demonstrates that
quality is taken seriously by our organisation and
that participation is a requirement for clinical
teams and individual clinicians as a means of
monitoring and improving their practice.
Participation in clinical research
The inclusion of this statement demonstrates the link
between our participation in research and our drive
to continuously improve the quality of services.
The number of patients receiving NHS services provided
or subcontracted by Gloucestershire Hospitals NHS
Foundation Trust in 2014/15, which were recruited during
that period to participate in research approved by an
NHS research ethics committee, and included on the
National Institute for Health Research (NIHR) Portfolio is
currently 1745. This figure includes recruitment recorded
on the NIHR Internet Portal up to 7th May 2015.
This figure is likely to increase over the next couple of
months as participants recruited to research studies in the
final weeks of the financial year continue to be reported.
If recruitment continues at a similar rate, we can expect a
final total for 2014/15 to be around 1,700 participants –
although it is always difficult to plan for seasonal variations
in recruitment and closure of high recruiting studies.
This would be similar to the total recruitment for the
previous year indicating a steady rate of recruitment
across a dynamic and ever changing portfolio.
We have not been set targets by the NIHR for the current
year as the networks are now looking at recruitment
across specialty areas, rather than at trust level.
During 2014/15, Gloucestershire Hospitals NHS
Foundation acted as host to 95 new studies approved
from 1st April 2014. Of these studies 55 were
adopted to the NIHR Portfolio. This is an increase
in total numbers, although the number of portfolio
studies is at a similar rate to the previous year.
In total the Trust was recruiting to 102 Portfolio Studies over
the 12 month period. This is a slight reduction from 2013/14
(110) but is an illustration of how the selection of studies for
the local portfolio, and their intended recruitment, is often
more important than simply the number of open studies.
There was a wide range of clinical staff participating in
research approved by an NHS Research Ethics Committee
during 2014/15. These staff participated in research
covering the majority of medical specialties across all four
divisions in Gloucestershire Hospitals NHS Foundation Trust.
40
2.3 | Statements of assurance
Table 1: Participation in National Audits
Audit title
Did the Trust
Participate?
Number of case submitted /
number required
Was the report
reviewed?
Actions taken as a result of audit / use of the database
Peri and Neonatal
Neonatal Intensive
and Special Care Audit
Programme (NNAP)
Yes
The NNAP uses the mandatory
database, ‘Badger’ to access all
records needed per question.
Yes – at Paediatric
Governance meetings
Badger has a number of places where data can be entered, but
NNAP doesn’t look at all of these. Data may be recorded, and
Badger says we have done so, but NNAP thinks we aren’t. This
has been highlighted by other trusts in letters to journals.
Areas of underscoring have been highlighted and discussed at
departmental level. Each set of notes is reviewed and checking
on Badger completion, manually. and checking of data manually
against notes.
As with many other units, we do not enter some data, e.g. 2 year
FU onto Badger at the moment.
Maternal, Newborn and
Infant Clinical Outcome
Review Programme
(MBRACE-UK)
Yes
All maternal deaths and
Data entered for all maternal deaths
stillbirths reviewed at
and still births
Governance meetings
Yes
296
Children
National Diabetes Audit
(PNDA) paediatric
Yes - at Paediatric
diabetes MDT meeting with Considering business case for additional nursing support
the divisional manager
Yes
56 cases submitted
Paediatric epilepsy clinical
governance meeting
Trust Epilepsy Policy written.
Improvements to the epilepsy database have led
to individualised care plans now available.
Development of evening clinics with more
of a focus on adolescents.
Setting up of a support group – not currently
available in Gloucestershire
Older People (care received
in Emergency Departments)
Yes
100 patients entered
To be reviewed at
specialty meetings
Report due to be published late Spring/early Summer 2015
Fitting child (care in
Emergency Departments)
Yes
50 patients entered
Report due to be published late Spring/early Summer 2015
Mental health (care in
Emergency Departments
Yes
50 patients entered
Report due to be published late Spring/early Summer 2015
Between April & December 2014:
98 (GRH) 37 (CGH). Ongoing
Yes – Resuscitation
committee
Risk Adjusted Comparative Analyses has allowed benchmarking
against the national picture. Results and points for discussion
are taken to the Resuscitation Committee, and from there points
of interest are then disseminated. Current actions include the
monitoring of ‘futile’ events with an aim to a reduction of these
‘futile’ events occurring, as a marker of quality. The Trust will be
undertaking root cause analysis on all cardiac arrests in 2014
16
Yes at respiratory
department meetings
Chest drain insertion proforma developed and currently being
trialled and re-audited
The reports provide information on mortality rates, length
of stay, etc and provide the Trust with an indication of our
performance and allows benchmarking against all units
nationally. Where trends are identified then these allow us to
make recommendations about changes to practice. Overall
good mortality & short length of stay especially for surgical
admissions. Quality indicators compare well with other units
Epilepsy 12
(Childhood epilepsy)
Acute Care
National Cardiac
Arrest Audit
Yes
Trust pleural procedures guideline written
Pleural procedure
Yes
Case Mix Programme
Yes
100% of patients admitted to
critical care areas - cases submitted
to 20/2/15 – 602 CGH, 719 GRH
Yes at quarterly business
and mortality meetings
Adult Community Acquired
Pneumonia
Yes
Currently in data collection phase
To be discussed at
respiratory department
meeting once published
41
2.3 | Statements of assurance
Audit title
Did the Trust
Participate?
Number of case submitted /
number required
Was the report
reviewed?
Actions taken as a result of audit / use of the database
Long term conditions
7 day services project ongoing to ensure respiratory specialist
opinion obtained within 24 hours, 7 days a week
All patients admitted with COPD
during data collection period of 1st
February – 30th April 2014 – CGH
56 cases included (63 submitted
but 7 excluded) GRH 85 cases
included (93 cases submitted but 8
excluded)
Report will be reviewed at
speciality and divisional
level
Yes
All renal dialysis and transplant
patients registered – current
numbers:
Haemodialysis: 244
Peritoneal dialysis: 42
Transplant: 174
Renal Team Audit
meetings. Latest report is
17th annual Report
National Diabetes Audit
(NDA) ADULT, includes
National Diabetes Inpatient
Adult (NADIA)
Yes
Planning for 13/14 data to be
submitted by June 2015
Report reviewed by
countywide Diabetes
Group and within medical
division
Inflammatory bowel disease
(IBD)
Yes
National Chronic Obstructive
Pulmonary Disease (COPD)
audit Programme
Renal replacement therapy
(Renal Registry)
Yes
Bowel Cancer (NBOCAP)
Head and neck oncology
(DAHNO)
Yes
Changes to be made to the admission care bundle
to improve recording of key information
To develop a COPD discharge care bundle
Extend the educational programme on spirometry
to hospital ward nurses and physios
Annual review of our performance. Below expected
performance triggers communication from UKRR
to Glos clinical lead and Medical Director
Results will be reviewed at
Gastroenterology Speciality
meetings once available
2014 report – 426 cases submitted
Reports discussed at the
annual business meeting
for the colorectal MDT
High data completeness and case ascertainment. Low mortality
and morbidity with high laparoscopic rates, high node yields and
low permanent stoma rates. Well below national average
83
Head & Neck Business
meeting, December 2014
Still trying to establish cause of delays in pathways.
Further CNS business plan and limitations of radiology and pathology support to MDT
The action plan will depend on the organisation of lung cancer
care within the trust which is currently a subject of ongoing
discussion
Yes
Reports discussed at the
annual business meeting
for the MDT & at the
Need to audit patients with respect to suitability for chemotherapy
Cancer Management Board as our numbers are lower than national comparators.
Oesophago-gastric cancer
(NAOGC)
Yes
129 cases submitted
Reports discussed at the
annual business meeting
98% case ascertainment
for the MDT & at the
Cancer Management Board
Rheumatoid and Early
Inflammatory Arthritis
Yes
17 patients entered to date
Will be discussed at
speciality meetings
National Prostate Cancer
Audit
Yes
90 patients submitted so far
Will be discussed at unit
audit and research group
No
The Trust requested to participate
in the pilot of this audit but was not
chosen. The Trust will register to
participate in the main audit with
data collection commencing April
2016
Lung cancer (NLCA)
National Audit of Dementia
1st year report due to published spring/summer 2015
42
2.3 | Statements of assurance
Audit title
Did the Trust
Participate?
Number of case submitted /
number required
Was the report
reviewed?
Actions taken as a result of audit / use of the database
Cardiovascular Disease
Yes at departmental
meetings and monthly
mortality and morbidity
meetings
Coronary angioplasty
Yes
CGH - cases of PCI performed
Acute coronary syndrome
or Myocardial Infarction
National Audit Project
(MINAP)
Yes
Yes – Shared with regional,
Emphasis on improving timings of response and analysis
100% for patients with ST elevation network and local
of patients with timings outside of standard
colleagues
National Heart Failure Audit
Yes
Yes 117 cases submitted
National Vascular Registry
Reports reviewed at
speciality meetings
Yes at specialty and
divisional meetings
Yes
Rated as excellent for data completeness
The waiting time from event to procedure has been shortened
from a median (range) of 97 (7-621) days in 2006 to 19 (5182) days in 2010 to 10 (2-88) days in 2014. NICE guidelines
state that this waiting time should be 14 days or less.
Time to wait for duplex scan has reduced from 41 (1-615)
days in 2006 to 3 (0-36) in 2010 to 2 (1-81) in 2014.
Surgery
Severe Trauma (Trauma
Audit and Research
Network, TARN)
Yes
187 cases submitted
Report reviewed jointly at
ED and T&O morbidity and
mortality meeting
Patient Reported Outcome
Measures (PROMs) measure quality
of a procedure from the patient
perspective. PROMs calculate the
health gain after surgical treatment
using pre and post operative
surveys.
Elective surgery (National
PROMs Programme)
Yes
Recruit data coordinator – April 2015
Implement TARN SQL script to facilitate monthly
completeness check (Information Dept) – May 2015
Improve data completeness
Actions taken with the division:
Patients are invited to participate,
it is not mandatory. Currently there
are four procedures being measured
groin hernias, varicose veins, total
knee and total hip.
ÆÆMonthly monitoring of patient participation
and forms returns from wards
ÆÆWeekly volunteer who visits wards to collect forms
ÆÆRegular reports by Consultant lead to surgical division.
Participation Rate:
ÆÆGroin hernia 54.5%
ÆÆHip replacement 68.2%
ÆÆKnee replacement 81.3%
ÆÆVaricose vein 55.6%
Falls and Fragility Audit
Programme (FFAP)
Sentinel Stroke National
Audit Programme (SSNAP)
Yes
About 700 cases per year, ongoing
every year for past 7 years
Reports reviewed at Hip
Fracture departmental
meetings, orthopaedic and
GOAM speciality meetings
Yes
All patients admitted with stroke
or TIA entered – 66 TIA cases and
1625 strokes 1625 cases entered
to date
Yes – Reviewed at
departmental meetings,
also at divisional and board
level
Multiple initiatives and changes made to
improve hip fracture service and care.
Funding secured for Clinical pathways manager for 1 year
to improve access to imaging and ward for the patients.
Business case being submitted for more therapists.
Review of Stroke and Neurology ward layout to improve
flow and experience for patients planned May 2015.
Organisational phase completed
National Emergency
Laparotomy Audit
Yes
In year one: 192 cases submitted by
GRH, 100 cases submitted by CGH
Currently in year 2 of patient data
collection phase.
Provision of all day access to emergency theatres at CGH.
Agreement cross county of best model for
Joint audit meeting Division provision of emergency general surgery.
of Surgery Jan 2015
Agreement and Implementation of agreed care pathway
bundle for patients undergoing emergency laparotomy
43
2.3 | Statements of assurance
Audit title
Did the Trust
Participate?
Number of case submitted /
number required
Was the report
reviewed?
All patients in GHNHSFT have their
details recorded on NJR (>95%
compliance)
National Joint Registry
Medical and Surgical
clinical outcome review
programme: National
confidential enquiry into
patient outcome and death
Yes
Yes
Trust continues to submit data
– 10th national report – 1064
patients’ data submitted (62%)
Annual report is reviewed
at Governance meetings
Gastro-Intestinal Haemorraghe
Study – 13 cases
Will be reviewed when
reports available at
specialty and divisional
meetings - report due June
2015
Sepsis study - 11 cases
Will be reviewed when
reports available at
speciality and divisional
meetings – report
due Autumn 2015
Lower limb amputation - 11 cases
Discussed at Divisional/
Speciality Level
Tracheostomy care - 11 cases
Discussed at Divisional/
Speciality Level
Discussed at Hospital
Transfusion committee
once available
National Comparative
Audit of Blood Transfusion
programme: 2 audits
participated in:
2014 National Comparative
Audit of Patient Information
and Consent for Blood
Transfusion
Yes
15 patients submitted
Audit of transfusion in
children and adults with
Sickle Cell Disease
Yes
3 cases submitted
Actions taken as a result of audit / use of the database
Data is entered retrospectively. Individual surgeons
to corroborate data to ensure accuracy
Ensure ODEP 10A hip implants and ODEP 10A knee
implants are used (or implants which are under review/
trial and have a satisfactory safety track record)
when ODEP rating becomes available (?2015)
Ensure surgeons are not ‘outliers’ on NJR funnel plots
and take appropriate steps if they become so.
The existing clinical care pathway for amputation
is being developed to more specifically address
the NCEPOD recommendations
Local CQuIN for the establishment of a Diabetic
Footcare team and pathway development
A pathway to be established for patients admitted
with tracheostomies and admitted to dedicated wards.
Trust policy to be reviewed and to consider simulation
training for ward staff in tracheostomy care
Patient consent and prescribing to be added to eLearning modules
for junior doctors (in addition to consent covered at induction)
Initiatives by NHS Blood & Transplant to be supported to
standardise information regarding risks and benefits
Report awaited
44
2.3 | Statements of assurance
Information on the use of Commissioning for
Quality & Innovation (CQUIN)  framework
The CQUIN payment framework continues to support
the cultural shift towards making quality the organising
principle of NHS services by embedding quality at
the heart of commissioner-provider discussions.
The agreed national, local and specialised CQUIN
schemes, the rationale behind them and the associated
payments for 2014/15 can be seen in Table 2 on p52.
The level of the Trust’s income in 2014/15 which
was conditional upon the quality and innovation
goals was £8,195,830 out of a total planned eligible
income of £327,833,200. In line with national rules
this represented about 2.5% of income (with 0.1%
removed from Specialised Income to support a ODN
national development fund). Current indications
show that £7,831,810 has been secured.
The main area of loss was the missed improvement
score for key questions in the National Inpatient
Survey, £226,680, which formed part of the local
Patient Experience CQUIN. There are several local
CQUINs where the final reports are awaited,
they are expected to deliver but until the final
audits are completed it is in guaranteed.
It is expected that all specialised CQUINs will also
meet requirements with only Quality Dashboards left
to report in Quarter 4. The CQUIN schemes agreed
for 2015/16 can be seen in Table 3 on p53. These
include three nationally mandated, five local schemes
and three schemes from specialised commissioning.
There is a high level of overlap between these goals
and the priorities in our Quality Account for 2015/16.
This demonstrates the high level of active engagement
with our commissioners in quality improvement.
It has been confirmed from national guidance that
the value of CQUIN schemes in 2015/16 has again
been set at 2.5% of total patient care income value.
The Care Quality Commission 
The Care Quality Commission (CQC) is the independent
regulator of health and adult social care services
in England. From April 2010, all NHS trusts have
been legally obligated to register with the CQC.
Registration is the licence to operate and to be
registered, providers must, by law, demonstrate
compliance with the regulatory requirements of
the CQC (Registration) Regulations 2009.
From April 2015 all providers will have to meet the
new Health and Social Care Act 2008 (Regulated
Activities) Regulations 2014 (Part 3) Gloucestershire
Hospitals NHS Foundation Trust (GHNHSFT) is
registered with the CQC without conditions.
This means that our Trust has continued to
demonstrate compliance with the regulations.
The Care Quality Commission visited us during
March 2015 as part of their new inspection regime.
The new inspections ask five key questions:
\\
Are they safe?
\\
Are they effective?
\\
Are they caring?
\\
Are they responsive to people’s needs?
\\
Are they well-led?
This results take the form of a rating for each
hospital - inadequate, requires improvement,
good or outstanding. The outcome of this visit
is expected to be published in June 2015.
From April 1 2015, all trusts will be expected to
publish the results of their CQC inspection as part
of the new regulations on their website and display
their rating prominently on hospitals sites. The latest
CQC Intelligent Monitoring Report is for May 2015.
45
2.3 | Statements of assurance
Table 2: 2014/15 CQUIN goals
Goal
No.
Measure
Weighting as % of
contract value
Actual value
of goal £
Quality
domain
0.167
547,480
Safety
0.167
547,480
Patient
Experience
0.167
544,200
Safety
0.38
999,420
Clinical
Effectiveness
0.63
1701,710
Patient
Experience
Range of initiatives predominantly addressing the emergency
care pathway, including: audit of compliance with the
implementation of choice policy, and caring for patients
in their last days of life (see related Goal 15 below)
1.0
2,701,130
Patient
Experience
& Safety
Description
National CQUIN goals (including specialised element)
1
NHS Safety Thermometer
2
Friends and family test
Pressure ulcers management including reduction in incidence
All patients aged >75 admitted as emergency:
3
Dementia
ÆÆ1. Case finding, assessment & specialist
ÆÆ2. Dementia clinical leadership plus staff training
ÆÆ3. Supporting Carers
Local CQUIN goals
5
COPD Admission
Care Bundle
6
Patient experience
escalator
7
Improving patient
flow and discharge
Care bundle  approach using BTS best practice
guidelines for admission COPD patients
ÆÆlearning from staff and patient experience
(data, including complaints)
ÆÆinvolving service users and staff in service review and redesign
ÆÆinvolving service users and staff in education and training
Specialised CQUIN goals
11
Quality dashboards
Continue from 12/13. Completion and return of data to
support national registries of clinical information
0.24
144,300
Clinical
Effectiveness
12
Hepatitis
To ensure use of MDTs  is optimised for best patient care
0.425
245,310
Clinical
Effectiveness
13
Cancer patient experience
To improve experience of patients in response to real-time surveys
0.425
245,310
Clinical
Effectiveness
14
Neonatal
Timely administration of total parenteral
nutrition (TPN) for preterm infants
0.475
274,170
Clinical
Effectiveness
15
Improving patient flow
Caring for patients in their last days of life (see related Goal 7 above)
0.425
245,310
Clinical
Effectiveness
2.5
8,195,830
TOTAL
46
2.3 | Statements of assurance
Table 3: 2015/16 CQUIN goals
Goal
No.
Measure
Description
Weighting as % of
contract value
Potential value
of goal £
Quality
domain
National CQUIN goals (including specialised element)
1
Acute Kidney Injury
To improve the follow up and recovery for
patients who have sustained AKI
0.25
626,360
Safety
2
Sepsis / Paediatric Sepsis
To screen all appropriate patients and to rapidly initiate
intravenous antibiotics within one hour or presentation for those
in septic shock, Red Flag sepsis or suspected severe sepsis
0.25
626,360
Safety
3
SAFER flow bundle
In line with the Urgent and Emergency Care Review,
this CQUIN aims to incentivise an increase in the
number of patients treated closer to home
0.5
1,252,720
Clinical
Effectiveness
4
Dementia & Delirium
To support the identification of patients with
dementia and delirium. Seek, assess, refer.
0.25
626,360
Safety
5
Planned process for the
transition from child
to adult services
To improve the planned process for children 16-25 to
transfer to ensure smooth transition to adult services.
To provide an individualised transition plan, using
a structured approach for all young adults
0.187
468,517.28
Patient
Experience
6
Configuring emergency
surgical services
Aims to standardise pathways to improve the quality of care
for patients undergoing an emergency laparotomy in the peri
operative period. ER improves the planned care pathway
for patients, reducing both the length of hospital stay.
0.187
468,517.28
Safety
7
Reduction in the number/
rate of lower limb
amputations through
the deployment of
a Multi-Disciplinary
Team Approach
The aim of this CQUIN is to improve diabetic foot care
with the aim of detecting foot ulcers earlier and then
onward referral to a formalised diabetic foot team for
treatment and to prevent unneccessary complications
0.187
468,517.28
Clinical
Effectiveness
0.5
1,252,720
Patient
Experience
0.187
468,517.28
Patient
Experience
Local CQUIN goals
The development of a process to deliver:
8
9
Cancer survivorship
Frailty
ÆÆA holistic needs assessment
ÆÆRisk Stratifying Pathway
ÆÆTreatment Summaries
ÆÆCare Plans
To provide a seamless care for frail older people that is
safe and compassionate. This CQUIN ensures assessment
and person centred care planning that can be effectively
communicated during admission and discharge.
Specialised CQUIN goals
10
Vascular Services Quality
Improvement programme
for outcomes of major
lower limb amputation:
Two year CQUIN
Improve mortality rates following major lower limb amputation
through the implementation of best practice guidance by
arterial vascular centres undertaking lower limb amputations
0.4
200,873
11
Increasing Home
Renal Dialysis
To achieve an increase in the % of dialysis patients who receive their
dialysis at home, either by peritoneal dialysis or home haemodialysis.
0.4
200,873
12
Reduce delayed discharges
from ICU to ward level
care by improving bed
management in wards
To identify why delays from ICU to ward based care occur and to
identify a scheme to reduce these delays to less than 24 hours
after decision to discharge made (in line with National Std)
0.4
200,873
13
2 Year Outcomes
for Infants <30
weeks gestation
The monitoring of 2 year outcomes to patient to avoid late
detection of neuro-developmen and/or learning disability and in
order to inform future service development and improvement.
0.4
200,873
Mandatory Clinical
Utilisation Review (CUR)
Clinical utilisation review (CUR) technology is used to provide
evidence-based decision support for clinicians to ensure patients
are cared for in the optimal setting and to reduce admission
rates, improve flow and discharge as well as, with commissioners,
right-size capacity in step down and community services to match
clinical need. Year 1 of this 2 year project consists of installation
and implementation with a planned wider rollout in year 2.
0.4
200,873
0.4
200,873
14
The development of a process to deliver:
15
Living with and
beyond cancer
ÆÆA holistic needs assessment
ÆÆRisk Stratifying Pathway
ÆÆTreatment Summaries
ÆÆCare Plans
Patient
Experience
47
2.3 | Statements of assurance
Quality of data
Good quality data underpins the effective delivery of
patient care and is essential if improvements in quality
of care are to be made. The patient NHS number is the
key identifier for patient records. Accurate recording
of the patient’s General Medical Practice Code is
essential to enable the transfer of clinical information
about a patient from a trust to the patient’s GP.
During 2014/15, Gloucestershire Hospitals
NHS Foundation Trust has taken the following
actions to improve data quality (DQ):
\\
all existing reports have been reviewed and revised
\\
routine DQ reports have now been automated and
are routinely available to all staff on the Trust intranet
via the Business Intelligence portal ‘Analyzer’
\\
we asked our internal auditors to audit the data
contributing to our performance indicators.
The Trust continues to work with an external partner to
advise the Trust on optimising the recording of clinical
information and the capture of clinical coding data.
Gloucestershire Hospitals NHS Foundation Trust has
submitted records during 2014/15 to the Secondary Users
Service (SUS) for inclusion in the Hospital Episode Statistics.
In data published for the period April to November 2014
(the most recent available as of May 2015), the percentage
of records which included a valid patient NHS number was:
\\
99.8% for admitted patient care
(national average: 99.2%)
\\
100% for outpatient care (national average: 99.3%)
\\
98.8% for accident and emergency
care (national average: 95.2%)
The percentage of published data which included
the patient’s valid GP practice code was:
\\
waiting list including duplicate
entries, same day admission.
On a weekly basis any missing/incorrect figures are
highlighted to staff and added or rectified. Our
Trust Data Quality Policy is published on the intranet
setting out responsibilities for data quality.
All Trust systems have an identified system manager
with data quality as a specified duty for this role. System
managers are required under the Clinical and Non- Clinical
Systems Management Policy to identify data quality issues,
produce data quality reports, escalate data quality issues
and monitor that data quality reports are acted upon.
Information Governance
The Trust’s Information Governance Toolkit score for 2014/15
remains 77%, the same as last year, and is graded green. The
Information Governance Toolkit is available on the Health and
Social Care Information Centre (HSCIC) website (igt.hscic.gov.
uk). The information quality and records management attainment
levels assessed within the Information Governance Toolkit provide
an overall measure of the quality of data systems, standards
and processes within an organisation. The effectiveness and
capacity of these systems is routinely monitored by our Trust's
Information Governance and Health Records Committee. A
performance summary is presented to our Trust Board annually
in March. In the period covered by this report there have been
no information governance breaches classified at level 1 or level
2 severity in accordance with HSCIC reporting guidelines.
Clinical coding error rate
GHNHSFT was subject to the Payment by Results clinical coding
audit during the reporting period by the Audit Commission and
the error rates reported in the latest published audit for that
period for diagnoses and treatment coding (clinical coding) were:
\\
Primary diagnosis 81%
\\
100% for admitted patient care (national average: 99.9%)
\\
Secondary diagnosis 78.3%
\\
100% for outpatient care (national average: 99.9%)
\\
Primary procedure 91.1%
\\
100% for accident and emergency
care (national average: 99.2%)
\\
Secondary procedure 73%
A comprehensive suite of data quality reports covering
the Trust’s main operational system (PAS) is available and
acted upon. These are run on a daily, weekly and monthly
basis and are now available through the Trust’s Business
Intelligence system, Analyzer. These include areas such as:\\
outpatients including attendances,
outcomes, invalid procedures
\\
inpatients including missing data such as
NHS numbers, theatre episodes
\\
critical care including missing data, invalid
Healthcare Resource Groups
\\
A&E including missing NHS numbers,
invalid GP practice codes
The results should not be extrapolated further than the
actual sample audited as these results reflect only a
small sample of patients coded during this quarter.
A sample of 200 Finished Consultant Episodes (FECs) were
audited: 100 were selected for the National area for audit
to inform the costing audit (HRG Sub-chapter FZ Digestive
system procedures and disorders); and the other 100
selected for the local area for audit which was highlighted
through benchmarking of data quality indicators (HRG
Sub-chapter DZ Thoracic procedures and disorders).
All data was from quarter 2 in financial year 2014/15.
It was evident that due to the number of FCE’s within
a spell, where an error happened in the first FCE, this
48
2.3 | Statements of assurance
error occurred in all the subsequent FCE’s which in
turn had a negative impact on the error rate.
GHNHSFT will be taking the following
actions to improve data quality:
\\
All errors uncovered during the course
of the audit fed back to the coding team
and any areas of training covered.
\\
Audit plan has been formulated ensuring that a follow
up audit of the areas examined during the course of
the PbR audit which is scheduled for December 2015.
\\
A new training plan has been put together to
ensure the coders have the skills to perform their
role, with specialty focussed training courses having
already been booked throughout the course of this
financial year. These courses are to be delivered
in part by the Trust’s Clinical Coding Manager,
who is also a CCS (Clinical Classifications Service)
Approved Experienced Trainer and Auditor.
\\
Individual coder audits will be carried out on a monthly
basis, with five spells each coder each month being
examined. This will serve to highlight potential training
issues/areas of concern and will inform whether
individual coders need to be audited more frequently.
\\
The department is striving to increase awareness
around the importance of accurate coded data
throughout the organisation. This is being achieved
through meetings with clinicians, divisional leads,
General Managers and Assistant General Managers.
\\
The Coding Manager is working with Patient
Records, Ward Clerks and clinical staff to ensure
patient case notes reach the coding department in
a timely manner and that appropriate information
and documentation is incorporated.
\\
The Coding Manager with some members of the
team is working with the Staff Development Team
at the Trust on an eLearning programme for Clinical
staff to improve their knowledge on Clinical Coding.
\\
The recruitment of a Clinical Coding Auditor to assist
with the audit process and ensure the ‘live audit’
option is achieved. This will ensure that any training
errors and areas of concern are addressed at the time
of coding, or within 4 working days of the coding
being entered onto the Trust PAS by the coder.
\\
Protected time to be given to coders at 30 minutes
per day to update the classifications with new
standards. This will also be covered to some
extent during the monthly team meetings, which
everyone attends, when any changes come in.
49
2.3 | Statements of assurance
Next section:
Reporting against core indicators
A review of our quality performance
2.3
Reporting against core indicators
A review of our quality performance
Since 2012/13 NHS foundation trusts have been
required to report performance against a core set of
indicators using data made available to the trust by the
Health and Social Care Information Centre (HSCIC).
Monitor, the Foundation Trust regulator, produces
guidance each year for the Quality Account, outlining
which performance indicators should be published
in the annual document. This year, as last year,
we have been required to publish data from the
HSCIC only for at least two reporting periods.
You can see our performance against these
mandated indicators in Table 4 on p51.
51
2.3 | Statements of assurance
Table 4: Reporting against core indicators
Indicator
(required by NHS England)
(a) SHMI for the trust for
the reporting period; and
(b) The percentage of patient
deaths with palliative care
coded at either diagnosis or
specialty level for the trust
for the reporting period.
Number of patient safety
incidents / number
which resulted in severe
harm or death
GHNHSFT
National
average
Highest
trust
figure
Lowest
trust
figure
Explanation of why GHNHSFT
considers that the data from
the HSCIC are as described
Actions GHNHSFT intends to
take to improve the indicator
and quality of services
2012/13
1.01
1.00
1.17
0.65
2013/14
1.06
1.00
1.19
0.54
Oct 13–
Sep 14
1.09
1.00
1.20
0.60
This indicator cannot be calculated
locally due to the requirement for
standardisation at national level.
GHNHSFT monitors crude mortality
using its own data. The banding
for all years is 'as expected'
Figures are as expected range compared
with other trusts. We have established
a Trust Mortality Review Group, chaired
by the Medical Director, which reviews
this indicator and other more granular
parameters in relation to mortality. We
also use the Dr Foster Intelligence System
to monitor mortality indicators.
2012/13
19.7%
19.9%
44.0%
0.1%
2013/14
21.0%
23.6%
48.5%
0.0%
Oct 13–
Sep 14
21.0%
25.3%
49.4%
0.0%
2012/13 8666 / 152
8488 / 59
14275
/ 212
3465 / 2
2013/14
8411 / 125
8890 / 54
15367
/ 183
2754 / 10
2014/15
4577 / 36
4196 / 20
12020 / 97
35 / 0
Year
2012/13 5.49 / 0.10 6.78 / 0.05
Rate per 100 admissions
of patient safety incidents
resulting / rate per 100
admissions resulting in
severe harm or death
Rate of C diff (per
100,000 bed days) among
patients aged over two
Percentage of patients
risk assessed for VTE
The percentage of patients
aged 0-15 readmitted to
hospital within 28 days
of being discharged
2013/14 5.64 / 0.08 7.14 / 0.04
2014/15 28.5 / 0.22 35.3 / 0.17
This indicator cannot be calculated
locally as it uses the same national
dataset as SHMI which includes
ONS data on post-hospital deaths.
A proxy using in-hospital data
only can be calculated but this is
not currently routinely reported
This places us close to the national
average and we do not regard ourselves
to be significantly different from it.
For years up to and including
2013/14, England, Highest and
Lowest are drawn from Large Acute
Trusts group only for trusts with
a full year of data in that cluster.
*For 2014/15 England, Highest
and Lowest are drawn from all
non-specialist acute trusts
Results are within the expected range
compared with other trusts. The Trust
will continue to encourage reporting of
patient safety incidents and carry out
root cause analysis investigations for
significant patient safety incidents.
For years up to and including
3.29 / 0.00 2013/14, England, Highest and
Lowest are drawn from Large Acute
11.76 /
Trusts group only and standardised
3.01 / 0.01
0.11
as 'per 100 admissions.' *For
2014/15 England, Highest and
Lowest are drawn from all
75.0 / 1.09 0.2 / 0.00 non-specialist acute trusts and
standardised as 'per 1,000 bed days'
13.17 /
0.14
2011/12
28.1
22.2
58.2
0.00
2012/13
20.6
17.3
30.8
0.00
2013/14
18.6
14.7
37.1
0.00
2012/13
93.6%
93.8%
100%
86.9%
2013/14
94.5%
95.7%
100%
82.0%
2014/15
93.2%
96.0%
100%
88.2%
2011/12
9.88%
10.26%
14.94%
6.40%
2012/13
N/A
N/A
N/A
N/A
2013/14
N/A
N/A
N/A
N/A
2014/15
N/A
N/A
N/A
N/A
Figures are within the expected range
compared with other trusts. The Trust
will continue to encourage reporting of
patient safety incidents and carry out
root cause analysis investigations for
significant patient safety incidents
We do not routinely calculate this
rate indicator, however the number
of cases for the year is consistent
with the figures we report internally.
Bed day numbers in both years are
approx 2% higher than our own
internal figures but this does not
affect the rate value calculated
We will continue to monitor key processes and
target areas that requirement improvement
Source: NHS England VTE Risk
Assessment Statistical Work Area.
National dataset compiled from
monthly local data submissions.
National indicator values may differ
slightly from locally calculated
values due to small variations in
assumptions for denominator
GHNHSFT intends to take the following
actions to improve this percentage and
so the quality of its services, by targeting
individual areas where performance
isn't meeting the required standard.
See p33 for more information
The data on the HSCIC has not
been updated beyond 2011/12.
This indicator is no longer
reported locally. The preferred
national and local indicator is now
readmissions within 30 days which
is broadly consistent with this
indicator. *Figure is standardised.
**Within large acute Trust
cluster in which our Trust lies
We have been working on a
range of initiatives to improve our
performance against this indicator
52
2.3 | Statements of assurance
Indicator
(required by NHS England)
Readmissions within 28
days: age 16 or over
Responsiveness to
inpatients' personal needs
Friends & Family Test Q12d
(If a friend or relative needed
treatment I would be happy
with the standard of care
provided by this organisation)
GHNHSFT
National
average
Highest
trust
figure
Lowest
trust
figure
Explanation of why GHNHSFT
considers that the data from
the HSCIC are as described
2011/12
10.52%
11.45%
13.80%
9.34%
2012/13
N/A
N/A
N/A
N/A
2013/14
N/A
N/A
N/A
N/A
2014/15
N/A
N/A
N/A
N/A
No national data has been published
since 2011/12. This indicator is
no longer reported locally. The
We have be working on a range
preferred national and local indicator
of initiatives to improve our
is now readmissions within 30 days
performance against this indicator
which is broadly consistent with
this indicator.**Within large acute
trust cluster in which our Trust lies
2012/13
68.0%
68.1%
84.4%
57.4%
Year
2013/14
67.3%
68.7%
84.2%
54.4%
2014/15
N/A
N/A
N/A
N/A
2012/13
56%
67%
89%
40%
2013/14
62%
68%
89%
38%
2014/15
N/A
N/A
N/A
N/A
Actions GHNHSFT intends to
take to improve the indicator
and quality of services
Data is taken from the Health &
Social Care Information Centre NHS
Outcomes Framework website under
the section 'Ensuring Patients Have
a Positive Experience of Care.' This
indicator is based on five questions
from the national inpatient survey.
We were pleased to note that our score
against 'Were you given enough privacy
when discussing your condition or
treatment?' was in the top 20% of trusts.
Data is taken from the National
Staff Surveys 2013 & 2014 which
is administered and analysed by a
third party. Q12d was introduced
to the Staff Survey in 2013. We
have use the cluster of acute trusts
for benchmarking the England
average, high and low values.
In 2014/15 we gave staff the opportunity to
answer this question on a quarterly basis.
You can read more about this on p24.
53
2.3 | Statements of assurance
Patient Reported Outcome Measures (PROMS)
Questionnaire, Oxford Hip Scores and Oxford Knee Scores – each
of which pose questions relating to the individual experience
of the patient with the condition. Patients complete these
surveys and questionnaires before and after their operations
and the difference in their scores are used as a measure of the
improvement resulting from their operation being carried out.
Patient Reported Outcome Measures (PROMs) collect
information on the effectiveness as perceived by the patients
themselves of the NHS care they have received. Since April
2009, patients undergoing four different types of elective
surgery – hip replacement, knee replacement, groin hernia
repair, varicose vein surgery – have been invited to complete
lifestyle questionnaires before and after their operations. Their
responses are converted into scores and when taken with other
clinical information, they allow the effectiveness of treatments
to be assessed and hospital providers to be compared.
The figures we have reported in Table 5 are the percentage
of patients reporting an improvement in their health and
wellbeing after their procedure as measured by each of the
questionnaires. The figure for the Trust is shown against
the England average improvement rate for comparison.
Two well-established general health and lifestyle surveys are
used – EQ-5D & EQ-VAS (EuroQol five-dimensional descriptive
health questionnaire and visual analogue scale) – alongside
condition-specific questionnaires – Aberdeen Varicose Vein
Table 5:
April 2012—March 2013 (final, published August 2014)
EQ-5D
Procedure
EQ VAS
Condition-specific Measure
Trust %
England %
Trust %
England %
Trust %
England %
Groin
46.7
50.2
34.7
37.7
Hip
89.9
89.7
63.4
65.5
96.3
97.1
Knee
79.9
80.6
52.2
54.9
94.5
93.2
Varicose Veins
45.8
52.7
45.1
40.9
86.8
83.3
April 2013—March 2014 (provisional, published February 13 2015)
EQ-5D
Procedure
EQ VAS
Condition-specific Measure
Trust %
England %
Trust %
England %
Trust %
England %
Groin
45.9
50.6
35.6
37.3
Hip
87.5
89.3
56.5
65.1
97.3
97.2
Knee
76.5
81.4
49.3
55.1
93.3
93.8
Varicose Veins
53.3
51.8
50.0
40.1
95.5
83.6
April—September 2014 (provisional, published February 13 2015)
EQ-5D
Procedure
EQ VAS
Condition-specific Measure
Trust %
England %
Trust %
England %
Trust %
England %
Groin
56.2
50.2
40.3
38.2
Hip
96.3
90.6
52.0
66.7
96.9
97.5
Knee
87.5
82.2
43.3
56.5
96.9
94.2
Varicose Veins
82.4
53.8
47.1
40.9
89.5
84.9
No condition-specific measure for groin surgery. Where numbers of cases are small, data is not published at Trust level to preserve patient confidentiality. There are shown as 'too few'.
Source: HSCIC website - Patient Reported Outcome Measures (PROMS) section. National data collated from locally-generated survey data
3
Other information
3 | Other information
Other information on the quality of our services
The following section presents more information
relating to the quality of the services we provide.
In Table 6 on p56 are a number of performance
indicators which we have chosen to publish which
are all reported to our Quality Committee.
The majority of these have been reported in previous
Quality Account documents. These measures have
been chosen because we believe the data from
which they are sourced is reliable and they represent
the key indicators of safety, clinical effectiveness
and patient experience within our organisation.
55
56
3 | Other information
Table 6: Other indicators we've chosen to report
2013/14
2014/15
National
target
for 14/15
Clostridium difficile year on year reduction: post 48 hrs
60
36
55
MRSA bacteraemia at less than half the 2003/4 level: post 48 hrs
1
2
0
MSSA*
17
30
N/A
Implementation of sepsis 6 bundle – 90% of patients in ED with severe sepsis receive 100% of the sepsis six bundle
97%
85%
N/A
Implementation of sepsis 6 bundle – 80% of patients in the hospital will receive 100% of the sepsis six bundle
85%
60%
N/A
Rate of Inpatient Falls per 1000 bed days
5.7
6.2
N/A
Rate of Medication Incidents per 1000 bed days
2.5
4.7
N/A
50%
77%
N/A
3
3
0
Indicators
Safety
COPD care bundle compliance
Never events
Hand washing compliance
Number of RIDDOR
N/A
2
4
N/A
Rate of Staff Falls per 1000 head count
2.1
1.3
N/A
Rate of Incidents arising from Clinical sharps per 1000 staff
0.6
2.6
N/A
Rate of physically violent and aggressive incidents occurring per 1000 staff
2.2
3
N/A
Global Trigger Tool
49.4
N/A
N/A
94%
100%
NHS Safety Thermometer
Risk assessment for patients with Venous ThromboEmbolsm (VTE)
94.7%
94.1%
95%
Crude mortality rate
1.34%
1.37%
N/A
Dementia 1a: Case Finding – 90% of eligible patients aged 75 years and over, as emergency admissions, asked the case finding question
80.7%
86.7%
90%
Dementia 1b: Clinical Assessment – 90% of eligible patients aged 75 years and over, as emergency
admissions will receive clinical assessment of their reported memory loss
100%
100%
90%
Dementia 1c: Referral for Management – 90% of eligible patients aged 75 years and over, as emergency admissions, who score positively on
the Abbreviated Mental Test (a test used to assess dementia), and where concerns over memory function remain will be referred onwards
86.3%
100%
90%
% patients spending 4 hours or less in ED
93.8%
90.2%
95%
Number of ambulance handovers delayed over 30 minutes
1157
1038
Number of ambulance handovers delayed over 60 minutes
798
142
Emergency readmissions within 30 days – elective & emergency
6.0%
6.2%
5.4%
Research Accruals
1686
1745§
N/A
Comparison of median time (months) to complete local governance checks
N/A
98%#
80%
% stroke patients spending 90% of time on stroke ward
82.8%
76.6%
80%
% women seen by midwife by 12 weeks
88.7%
89.6%
90%
Number of written complaints
837
904
N/A
Rate of written complaints per 1000 inpatient spells
5.6
6.2
N/A
Effectiveness
Patient Experience
57
3 | Other information
Indicators
2013/14
2014/15
National
target
for 14/15
Number of comments on NHS Choices: Positive / Negative
60/27***
87/31
N/A
Number of comments Patient Opinion: Positive / Negative
17/5***
60/22
N/A
Max 2 week wait for patients urgently referred by GP
93.9%
92.0%
93%
Max 2 week wait for patients referred with non cancer breast symptoms
88.7%
87.5%
93%
Max wait 31 days decision to treat to treatment
99.7%
99.7%
96%
Max wait 31 days decision to treat to subsequent treatment : surgery
100%
99.4%
94%
Max wait 31 days decision to treat to subsequent treatment: drugs
100%
100%
98%
Max wait 31 days decision to treat to subsequent treatment: Radiotherapy
100%
99.7%
94%
Max wait 62 days from urgent GP referral to 1st treatment (exl. rare cancers)
81.0%
82.4%
85%
Max wait 62 days from national screening programme to 1st treatment
96.0%
93.1%
90%
Max wait 62 days from consultant upgrade to 1st treatment
88.9%
94.3%
90%
18 week maximum wait from point of referral to treatment (admitted patients adjusted)
92.3%
95.1%
95%
18 week maximum wait from point of referral to treatment (non-admitted patients unadjusted)
97.3%
92.1%
92%
Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways ◊
92.0%
92.2%
92%
* April 2014–March 2015 data
** April 2014 - December 2014
*** August 2013 - March 2014
§ 2014/15 figure may continue to increase into 2015/16 due to delays in reporting processes
#
Approval times are recorded on a rolling basis and older results are not available. Although the exact figure for 2013/14 is not available, overall the Trust was rated 'green' at over 80%
of approvals within 15 days of receipt of a Valid Research Application
◊ Management response in relation to the auditor's opinion on this measure: “We are pleased to see that all the 12 admitted cases were correctly recorded. For the 10 non admitted
cases that were incorrectly recorded these errors would either be picked up prior to the time of offering patient treatment or would be subject to validation through the internal
trust validation process. There is a programme of ongoing training for administrative staff to ensure that the 18 rules for clock starts and stops are known and applied. This
training will be reviewed in light of this conclusion. For the cases identified the errors did not have any impact on the quality of patient care provided”. Read the full Limited
Assurance Report to the Council of Governors of GHNHSFT on the Quality Report on p62
Next part:
Annex 1: Statements from
stakeholder organisations
A1
Annex 1:
Statements from stakeholder organisations
59
Annex 1 | Statements from stakeholder organisations
Statement from Gloucestershire Clinical Commissioning Group
NHS Gloucestershire Clinical Commissioning Group
(CCG) welcomes the opportunity to provide comments
on the Quality Account prepared by Gloucestershire
Hospitals NHS Foundation Trust (GHNHSFT) for 2014/15.
The past year has presented major challenges across
both Health and Social Care in Gloucestershire. The
CCG acknowledge where GHNHSFT have worked with
the CCG and other providers to deliver a whole system
approach, which we hope will continue in 2015/16.
The combined pressures on the system have made
it difficult to achieve the national four hour target
to see, treat, admit or discharge every patient that
attends the Emergency Department. The CCG have
provided additional resources to improve performance
in relation to these emergency pressures and will
continue to work with the trust to achieve this
target and improve the patient experience.
The 2014/15 Quality Account is easy to read and
understandable given that it has to be considered by range
of stakeholders with varying levels of understanding. Some
of the graphs and charts would have benefitted from
further narrative to explain the detail and to benchmark
data with similar providers. The Quality Account describes
the trust performance overall and there are some areas,
such as mortality, where it would have been helpful
to separate Cheltenham and Gloucester activity.
The CCG note the priorities for improving quality for
next year and would like it to be recognised that all
areas identified are also priorities for commissioners.
The CCG welcome the strong focus on patient experience.
GHNHSFT have described three excellent patient
experience projects to tackle issues of communication,
patient needs and working together during 2015/16.
These three projects, Listening and Learning, Shadowing
and Experience-based Co-design, will inform Clinical
Programme Group discussions, and it will be interesting
to read how these projects have progressed in next year's
Quality Account. It would have been helpful to have seen
examples from this year's Learning from Feedback project
to provide feedback of individual patient experience.
The CCG would like to commend the
excellent section on #hellomynameis.
The information on Audit and Research is a strength
of the Account however it would have been
enhanced with specific actions and improvements
to arise from the outcome of these activities.
Health and wellbeing of staff is a priority for the CCG and
we welcome GHNHSFT focus on reducing violence and
aggression towards staff. This year saw the introduction
of the staff Friends and Family test, and uptake of this was
low. It is noted that the Staff Survey was an improvement
from last year and the CCG hope to see a continued
improvement in this area as feedback from staff is a
key indicator of the performance of an organisation.
The CCG notes that there are some significant quality
issues that they have been aware of that have not
been mentioned in the Account; these were delays in
diagnostic reporting and outpatient clinic letters. Further
information on these would have been welcomed in the
document. There has been improvement in performance
over the year and the CCG look forward to working with
GHNHSFT over the next year to continue to improve this.
GHNHSFT were inspected by the CQC during March
and at the time of responding to this Quality Account
the outcome is not available. The CCG anticipate
that any resulting recommendations and action
plans will be shared in next year's Account.
Gloucestershire CCG can confirm to the best of our
knowledge that we consider that the Quality Account
contains accurate information in relation to the quality
of services provided by GHNHSFT. During 2015/16 the
CCG would like to work with all providers, stakeholders
and the population of Gloucestershire to develop ways
of receiving the most comprehensive reassurance we
can regarding the quality of the services provided
to the residents of Gloucestershire and beyond.
Marion Andrews-Evans
Executive Nurse & Quality Lead
60
Annex 1 | Statements from stakeholder organisations
Statement from Healthwatch Gloucestershire (HWG)
This is the second year in which HWG has had the
opportunity to be involved with the Trust's Quality Account
and we are pleased to provide the following comments.
General Comments
The Quality Account is just one of an increasing
number of ways in which HWG is able to work with
the Trust to ensure that the things that the public
tell us e.g. problems, suggestions, examples of
good practice etc, are communicated to the Trust
to support their focus on improving services.
HWG regularly meet with senior managers in the Trust
and with the Trust Chair, and this year we were pleased
to be invited to the Trust Board and Quality Committee to
discuss topics of particular concern and to input directly
to the Quality Account priorities for 2015/16. We have
also been able to join the Trust's Patient Experience
Strategy Group and a range of other internal groups,
which reflects well on the Trust's willingness to involve
patients and lay people in the development of services.
We look forward to extending the range of ways
in which we can work on behalf of the public with
the Trust and its commissioner (Gloucestershire
Clinical Commissioning Group) in 2015/16.
Generally, we feel this Quality Account provides an
interesting, comprehensive and readable picture of
the organisation's work. In particular the sequence of
material is helpful to the reader, with past performance
coming first and setting a logical context for future
priorities, and we feel there is a good balance of
material between past performance and future plans.
There is an effective mix of text and statistical and
graphical information. Complex topics, such as pressure
ulcers, have been well explained using diagrams.
However, there are few if any patient stories in
this year's account. We felt these were particularly
useful in 2013/14 in demonstrating the impact
of hospital care, and we would like the Trust to
reconsider their use for future Quality Accounts.
How well have we done in 2014/15?
We welcome the tabular presentation of original
quality improvement priorities in 2014/15 and the
way in which it is possible to see the issues that
various organisations have identified, and to see
the 2015/16 priorities in a consistent format.
Safety
NHS Safety Thermometer: There has clearly been a great
deal of effort on several fronts to promote ‘harm free’ care.
It is therefore of concern both that the volume of pressure
ulcers is not showing a long-term decline and that the
Quality Account does not report clearly the reasons for the
continued increase. We hope that the further improvement
measures will halt the long-term increase from 2015/16.
Improving the Management of patients with
Sepsis: There is a similar presentation in this section
where performance for all of the reported months in
2014/15 has not met the compliance target. It would
be really useful for lay readers if the Account could be
clearer about what needs to happen to close the gap
between performance and target, and about assurance
that the intentions in 2015/16 will improve performance.
The COPD section of the account appears to
demonstrate a clear and welcome confirmation of
improved performance and impacts for patients.
Likewise, in Improving Care for Patients with Dementia
and Delirium, there is comprehensive information about
the range of measures that have been taken. However, it
is less easy to understand how and when those improved
inputs and resources will translate into the sustained
achievement of target case-finding performance.
Reducing the incidence of Never Events: While the
text confirms a determination to learn lessons from such
regrettable events, we were concerned to see that this area
has not been carried forward as a Safety Priority in 2015/16.
Supporting Patient Flow: We welcome the Trust's focus
on how people move through the hospitals and on ensuring
a balance between safety, effective care and good patient
experience. We regularly receive critical feedback from
people about how they were discharged from hospital and
we have conducted a detailed study about it this year. We
recognise the challenges that have arisen during 2015/16
and the trajectory for 4-hour wait is especially problematic.
It would have been useful to read an overall commentary
that combined the various statistical sources with
information from qualitative sources (PALS / complaints,
partner comments). It is not easy to understand from the
Account's data sources what the impact for patients has
been of, for example, the 4-hour wait performance.
While, for example, Length of Stay provides a statistical
61
Annex 1 | Statements from stakeholder organisations
insight into the efficiency of "flow", we very much hope
for the future that it will be possible to provide more
qualitative insights into how patients experience movement
through the hospital system and discharge from it.
and to continuing to provide independently gathered
sources of information to support these projects.
Patient Experience
Claire Feehily
Chair, Healthwatch Gloucestershire
We welcome the range of ways in which the Trust is
collecting information from people about how they
experience treatment, and actively involving patients
and lay people in the development of services.
In this review of what was learned in 2014/15 it would
have been useful to read a summary of what the Trust
learned from such sources in the year, eg what were the
key themes emerging from PALS and Complaints? That
would provide a helpful context in which to consider
the priorities for 2015/16. It would also highlight the
demonstrable connection between what patients
say about their care and how the Trust responds.
What are our priorities for 2015/16?
HWG was able to present its issues to the Trust's Quality
Committee and we are pleased that they have been
included. We would also like to see continued focus on
high-quality services for those with sensory impairments.
Safety and Clinical Effectiveness
Each of the specific areas of focus is very welcome. It
will be important in-year to devise measurable and
transparent improvement targets to accompany the
various plans and interventions that are described in
the Account. So, for example, what is the planned
reduction in ulcers arising from the SSKIN initiative
and continued awareness raising? And similarly in
time, what will the planned revised wait times be for
patients in the ophthalmology department? And by how
much will the number of missed fractures reduce?
We very much welcome the focus given to improving the
discharge of patients. The recognition that the quality
of a patient's experience of discharge needs to be a
central focus is also welcome. We hope to support the
Trust in its work on this priority in 2015/16 by sharing
the material that we have gathered from patients, carers,
voluntary organisations, GPs, and care home providers.
In particular we hope that this work will recognise
that patients often move between different NHS and
other providers and that a true understanding and
improvement of their experience will need to encompass
feedback from across organisation boundaries.
Patient Experience
Although a relatively short part of the Account, the
intentions that are summarised at 2.1.2 will have significant
implications for how the Trust involves patients in the
development of services. We look forward to seeing the
development of some SMART objectives for this work,
62
Annex 1 | Statements from stakeholder organisations
Statement from Gloucestershire Health and Care
Overview and Scrutiny Committee
On behalf of the Health and Care Overview and Scrutiny
Committee I welcome the opportunity to comment
on the Gloucestershire Hospitals NHS Foundation
Trust (GHNHSFT) Quality Account 2014/15.
For the committee, the patient journey and experience
continues to be the main concern and members have
again asked that the patient experience be marked
as a priority for the committee. I welcome the Trust’s
continued commitment to delivering compassionate care. In
commenting on last year’s Quality Account, I indicated that
I would welcome information on how the Trust will measure
whether it is achieving this aim and, whilst it is clear that
the Friends and Family Test and complaints/compliments
will offer some insight, I would again ask that it is made
clearer as to how the Trust will measure this aspect.
I also welcome that staff at the Trust have joined the
#hellomynameis campaign. Making this initial (personal)
contact with a patient is an important starting point in
the patient/clinician relationship. I hope that the Trust
continues to support staff involvement in this campaign.
However whilst acknowledging and welcoming the Trust’s
commitment to patient care this public commitment
does not seem to tally with the situation that arose
last year with regard to significant delays in radiology
and cardiology reports. This was exacerbated by the
committee learning about this from the Gloucestershire
Local Medical Committee rather than the Trust. The
committee has been advised that this situation has been
resolved but has not been informed whether this had
any adverse impact on any patient’s health outcomes.
I must emphasise that the committee expects all partners
to work effectively together for the benefit of the people
of Gloucestershire. All organisations are under pressure and
working effectively together is the only way to overcome
these pressures. Committee members will, therefore,
not tolerate a repeat of the situation at the end of 2014
where actions by the GHNHSFT damaged partnership
working in this county. Thankfully due to prompt action
by the committee and strong leadership by the Chair
of the Gloucestershire Clinical Commissioning Group,
the Cabinet Member for Older People and the Chairs
of the NHS Trusts this situation has been recovered.
Performance against some of the cancer targets
has been of concern for the committee over the
last 12 months. It is therefore good to note that
cancer survivorship is identified as a priority for the
Trust and the committee supports this position.
The committee has also expressed some concern around
targets relating to stroke services. I am pleased to note
the project in place between the clinicians and patients as
to how this service can be improved. The committee will
be interested to understand the outcome of this project.
The pressures on the Trust which led to calling
a major internal incident in December 2014 are
significant and I must praise the hard work of
the staff at the Acute Hospitals for their ongoing
professionalism and commitment to their patients.
I also want to particularly thank Professor Clair
Chilvers, Dr Frank Harsent, Dr Sally Pearson
and Eric Gatling for attending meetings and
responding to members many questions.
Cllr Steve Lydon
Chairman
63
Annex 1 | Statements from stakeholder organisations
Next part:
Independent Auditor's Limited Assurance
Report
64
Annex 1 | Statements from stakeholder organisations
Independent Auditor’s Limited Assurance Report to the Council of Governors
of Gloucestershire Hospitals NHS Foundation Trust on the Quality Report
We have been engaged by the Board of Directors and
Council of Governors of Gloucestershire Hospitals NHS
Foundation Trust to perform an independent limited
assurance engagement in respect of Gloucestershire
Hospitals NHS Foundation Trust’s Quality Report for the
year ended 31 March 2015 (the ‘Quality Account’) and
certain performance indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2015
subject to limited assurance consist of the national
priority indicators as mandated by Monitor:
\\
percentage of incomplete pathways within 18
weeks for patients on incomplete pathways
at the end of the reporting period
\\
maximum waiting time of 62 days from urgent
GP referral to first treatment for all cancers.
We refer to these national priority indicators
collectively as the ‘indicators’.
Respective responsibilities
of the directors and auditor
The directors are responsible for the content and the
preparation of the Quality Account in accordance
with the criteria set out in the ‘NHS Foundation Trust
Annual Reporting Manual’ issued by Monitor.
Our responsibility is to form a conclusion, based on
limited assurance procedures, on whether anything has
come to our attention that causes us to believe that:
\\
the Quality Account is not prepared in all material
respects in line with the criteria set out in the ‘NHS
Foundation Trust Annual Reporting Manual’
\\
the Quality Account is not consistent in all
material respects with the sources specified
in Monitor's 'Detailed guidance for external
assurance on quality reports 2014/15’, and
\\
the indicators in the Quality Account identified as
having been the subject of limited assurance in the
Quality Account are not reasonably stated in all material
respects in accordance with the ‘NHS Foundation Trust
Annual Reporting Manual’ and the six dimensions
of data quality set out in the ‘Detailed guidance for
external assurance on quality reports 2014/15’.
We read the Quality Account and consider whether
it addresses the content requirements of the ‘NHS
Foundation Trust Annual Reporting Manual’, and
consider the implications for our report if we
become aware of any material omissions.
We read the other information contained in
the Quality Account and consider whether
it is materially inconsistent with:
\\
Board minutes for the period 25
April 2014 to 24 April 2015
\\
papers relating to quality reported to the board
over the period 25 April 2014 to 24 April 2015
\\
feedback from Commissioners, dated 12 May 2015
\\
feedback from Governors, dated 4 February 2015
\\
feedback from local Healthwatch
organisations, dated 6 May 2015
\\
feedback from Overview and Scrutiny
Committee, dated 14 May 2015
\\
the Trust’s complaints report published under regulation
18 of the Local Authority Social Services and NHS
Complaints Regulations 2009, dated 20 June 2014
\\
the national patient survey (for Accident and
Emergency patients), dated November 2014
\\
the national staff survey, dated 13 February 2015
\\
Care Quality Commission Intelligent
Monitoring Report, dated May 2015
\\
the Head of Internal Audit’s annual opinion over the
Trust’s control environment, dated May 2015; and
\\
the draft Trust complaints report for 2014/15.
We consider the implications for our report if we
become aware of any apparent misstatements or
material inconsistencies with those documents
(collectively, the ‘documents’). Our responsibilities
do not extend to any other information.
We are in compliance with the applicable independence
and competency requirements of the Institute of
Chartered Accountants in England and Wales (ICAEW)
Code of Ethics. Our team comprised assurance
practitioners and relevant subject matter experts.
This report, including the conclusion, has been prepared
solely for the Council of Governors of Gloucestershire
Hospitals NHS Foundation Trust as a body and the
Board of Directors of the Trust as a body, to assist
the Board of Directors and Council of Governors in
reporting Gloucestershire Hospitals NHS Foundation
Trust’s quality agenda, performance and activities. We
permit the disclosure of this report within the Annual
Report for the year ended 31 March 2015, to enable
the Board of Directors and Council of Governors to
demonstrate they have discharged their governance
responsibilities by commissioning an independent
assurance report in connection with the indicators. To
the fullest extent permitted by law, we do not accept or
assume responsibility to anyone other than the Board
65
Annex 1 | Statements from stakeholder organisations
of Directors as a body, the Council of Governors as a
body and Gloucestershire Hospitals NHS Foundation
Trust for our work or this report, except where terms are
expressly agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement in
accordance with International Standard on Assurance
Engagements 3000 (Revised) – ‘Assurance Engagements
other than Audits or Reviews of Historical Financial
Information’, issued by the International Auditing
and Assurance Standards Board (‘ISAE 3000’).
Our limited assurance procedures included:
\\
evaluating the design and implementation
of the key processes and controls for
managing and reporting the indicators
\\
making enquiries of management
\\
analytical procedures
\\
limited testing, on a selective basis, of
the data used to calculate the indicator
back to supporting documentation
\\
comparing the content requirements of the ‘NHS
Foundation Trust Annual Reporting Manual’ to the
categories reported in the quality report and
\\
reading the documents.
A limited assurance engagement is smaller in scope
than a reasonable assurance engagement. The
nature, timing and extent of procedures for gathering
sufficient appropriate evidence are deliberately limited
relative to a reasonable assurance engagement.
Limitations
Basis for qualified conclusion
The indicator percentage of incomplete pathways
within 18 weeks for patients on incomplete pathways
at the end of the reporting period did not meet the six
dimensions of the data quality in the following respects:
Accuracy - of the sample of 25 incomplete pathways
reviewed, 13 related to the non-admitted pathway
and 10 of these were incorrectly recorded. The errors
identified fell into two different categories: either the
clock was incorrectly started or the clock was not
stopped when the patient received treatment.
Qualified conclusion
Based on the results of our procedures, with the
exception of the matters reported in the basis for
qualified conclusion paragraph above, nothing has
come to our attention that causes us to believe
that, for the year ended 31 March 2015:
\\
the Quality Account is not prepared in all material
respects in line with the criteria set out in the 'NHS
Foundation Trust Annual Reporting Manual';
\\
the Quality Account is not consistent in all material
respects with the sources specified above; and
\\
the indicators in the Quality Account subject to
limited assurance have not been reasonably stated
in all material respects in accordance with the 'NHS
Foundation Trust Annual Reporting Manual'.
Grant Thornton UK LLP
Bristol
May 2015
Non-financial performance information is subject to
more inherent limitations than financial information,
given the characteristics of the subject matter and the
methods used for determining such information.
The absence of a significant body of established practice
on which to draw allows for the selection of different,
but acceptable measurement techniques which can result
in materially different measurements and can affect
comparability. The precision of different measurement
techniques may also vary. Furthermore, the nature and
methods used to determine such information, as well
as the measurement criteria and the precision of these
criteria, may change over time. It is important to read the
Quality Account in the context of the criteria set out in
the ‘NHS Foundation Trust Annual Reporting Manual’.
The scope of our assurance work has not included
governance over quality or non-mandated
indicators, which have been determined locally by
Gloucestershire Hospitals NHS Foundation Trust.
*See p55 for the management response in relation to the ‘percentage of incomplete
pathways within 18 weeks for patients on incomplete pathways’ indicator.
A2
Annex 2:
Statements of directors’ responsibilities
67
Annex 2 | Statements of directors’ responsibilities
Statement of directors' responsibilities for the Quality Account
The directors are required under the Health
Act 2009 and the National Health Service
(Quality Accounts) Regulations to prepare
quality accounts for each financial year.
Monitor has issued guidance to NHS foundation trust
boards on the form and content of annual quality
reports (which incorporate the above legal requirements)
and on the arrangements that NHS foundation
trust boards should put in place to support the data
quality for the preparation of the quality report.
In preparing the Quality Report, directors are
required to take steps to satisfy themselves that:
robust and reliable, conforms to specified data
quality standards and prescribed definitions, is
subject to appropriate scrutiny and review and
\\
the Quality Report has been prepared in accordance
with Monitor's annual reporting guidance (which
incorporates the Quality Accounts regulations)
(published at www.monitor.gov.uk) as well as
the standards to support data quality for the
preparation of the Quality Report (available at
www.monitor.gov.uk/annualreportingmanual).
The directors confirm to the best of their knowledge
and belief they have complied with the above
requirements in preparing the Quality Report.
By order of the Board,
\\
the content of the Quality Report meets
the requirements set out in the NHS
Foundation Trust Annual Reporting Manual
2014/15 and supporting guidance
\\
the content of the Quality Report is not
inconsistent with internal and external
sources of information including:
\\ board minutes and papers for the
period April 2014 to May 2015
\\ papers relating to the Quality reporting to the
board over the period April 2014 to May 2015
\\ feedback from commissioners dated 12/05/15
\\ feedback from governors dated 06/05/15
\\ feedback from local HealthWatch
organisations dated 06/05/15
\\ feedback from Overview and Scrutiny
Committee dated 14/05/15
\\ the trust's draft complaints report to be
published, under regulation 18 of the Local
Authority Social Services and NHS Complaints
Regulations 2009, in June 2015
\\ the 2014 national patient survey (Accident
& Emergency) dated November 2014
\\ the 2014 national staff survey dated February 2015
\\ the Head of Internal Audit's annual opinion over
the trust's control environment dated May 2015
\\ the draft CQC Intelligent Monitoring
Report to be published on 29/05/15
\\
the Quality Report presents a balanced
picture of the NHS foundation trust's
performance over the period covered
\\
the performance information reported in the
Quality Report is reliable and accurate
\\
there are proper internal controls over the
collection and reporting of the measures of
performance included in the Quality Report, and
these controls are subject to review to confirm
that they are working effectively in practice
\\
the data underpinning the measures of
performance reported in the Quality Report is
Dr Frank Harsent
Chief Executive
Clair Chilvers
Chair
Gloucestershire Hospitals
NHS Foundation Trust
Gloucestershire Hospitals
NHS Foundation Trust
May 2015
May 2015
G
Glossary of abbreviations and terms
69
Glossary
Abbey Pain Score – The Pain Scale is
an instrument designed to assist in the
assessment of pain in patients who are
unable to clearly articulate their needs
CTG - this is a technical means
of recording the fetal heartbeat
and the uterine contractions
during pregnancy and labour.
Academic Health Science
Networks – are new partnerships
responsible for driving improvements
in patient care by sharing innovations
across the NHS. Their creation was
announced in December 2011 in the
Government’s ‘Innovation, Health
and Wealth’ report as a way to align
education, clinical research, informatics,
innovation, training, education and
healthcare delivery at a local level.
DVT – Deep Vein Thrombosis. This is the
formation of a blood clot (thrombus) in
a deep vein, predominantly in the legs
App - an application (or piece of
software) which can be installed
onto a digital device to help them
perform a particular task.
C. Difficile – Clostridium difficile,
also known as CDF/cdf, or C. diff,
is a species of Gram-positive sporeforming bacteria that is best known for
causing antibiotic-associated diarrhea
Care bundle – A care bundle is
a set of clinical interventions that,
when used together, significantly
improve patient care.
CGH – Cheltenham General Hospital
Clinical Commissioning Group –
From April 1, 2013, our commissioners
became the Gloucestershire Clinical
Commissioning Group. Commissioning
is the process of assessing the needs
of a local population and putting in
place services to meet those needs.
Commissioners are those who do this and
who agree service level agreements with
service providers for a range of services.
COPD – Chronic obstructive pulmonary
disease is the name for a collection
of lung diseases including chronic
bronchitis, emphysema and chronic
obstructive airways disease.
CQUIN– This stands for the
Commissioning for Quality and
Innovation payment framework.
The motivation behind CQUINs is
to reward excellent performance by
linking a proportion of providers'
income to the achievement of local
quality improvement goals.
Emergency Department –
Otherwise known as A&E
GHNHSFT – Gloucestershire
Hospitals NHS Foundation Trust
Healthwatch Gloucestershire
– Healthwatch was established in
April 2013 and is the new consumer
champion of the health and social
care in England, giving children, young
people and adults a powerful voice
Governors – Members can become
more involved by standing for election
as a governor and representing their
fellow members’ views on the Council
of Governors. Governors play an
important role in the governance of
the Trust. They represent the views
of patients, carers and patients.
GRH – Gloucestershire Royal Hospital
HCAI – Health Care Associated Infections
- such as Clostridium difficile or MRSA
HCOSC – Gloucestershire Health and
Care Overview and Scrutiny Committee.
This is a body which scrutinises the
decisions of local health organisations
Members – As an NHS Foundation
Trust we are accountable to our local
community. This means we give greater
say in how we’re run to local people,
staff and all those who use our services
including patients, their families and
carers. Each foundation trust must
recruit ‘members’ to reflect these
groups and help us ensure that we are
providing the best service we can.
MDTs - Stands for Multidisciplinary Team,
which is a team composed of members
from different healthcare professions
with specialised skills and expertise.
MRSA – Methicillin-Resistant
Staphylococcus Aureus. This is a type
of bacterial infection that is resistant
to a number of widely used antibiotics.
This means it can be more difficult to
treat than other bacterial infections.
MSSA – Methicillin-Sensitive
Staphylococcus Aureus. Staphylococcus
aureus is a very common bacterium
(germ) that around 30% of the
population carry on their skin or on the
lining of their nose and throat without
knowing. Usually this germ is harmless.
Sometimes it can cause local infections
such as abscesses or boils and it can
infect any wound that has caused a break
in the skin eg. grazes or surgical wounds.
NHS Litigation Authority - A nonprofit making part of the NHS which
manages negligence and other
claims against the NHS in England.
NHS Safety Thermometer - a quick
and simple method for surveying
patient harms and analysing results
so that you can measure and
monitor local improvement and
harm free care (external) (Opens
in a new window) over time.
Regulators – The Care Quality
Commission (CQC) regulates all health
and adult social care services in England,
including those provided by the NHS,
local authorities, private companies or
voluntary organisations. It also represents
the interests of people detained under
the Mental Health Act. Monitor is also
another regulatory body, responsible
for safeguarding choice, protecting and
promoting the interests of patients.
SEAP – a free, independent and
confidential advocacy service which helps
resolve issues or concerns a patient may
have about their health and wellbeing
or their health and social care services.
Sepsis Six – A simple set of six
tasks, known as a care bundle, which
should be delivered by doctors or
nurses within 1 hour of diagnosis.
Venous thromboembolism (VTE)
– This is a disease that includes
Deep Vein Thrombosis (DVT) and
pulmonary embolism (PE)
Waterlow Scoring System – The
Waterlow score (or Waterlow scale) gives
an estimated risk for the development
of a pressure sore in a given patient.
The tool was developed in 1985 by
clinical nurse teacher Judy Waterlow.