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Contents
Part 1: Information About the Quality Account ......................................................................... 4 What is a Quality Account? ...................................................................................................... 5 Statement of Director’s responsibilities in respect of the Quality Account .................................. 8 Statement on Quality from the Chief Executive ......................................................................... 9 Part 2: Priorities for improvement and statement of assurance from the Board ....................... 12
Quality Improvement Priorities for 2015-16 ............................................................................ 13 Priority 1: Safety ..................................................................................................................... 14 Priority 2: Effectiveness ........................................................................................................... 17 Priority 3: Caring .................................................................................................................... 18 Priority 4: Responsive.............................................................................................................. 19 Priority 5: Well-led .................................................................................................................. 20 Statements of assurance from the Board ................................................................................ 22 Review of Quality Priorities 2014-15 ....................................................................................... 34 Priority 1: Safety ..................................................................................................................... 34 Priority 2: Clinical Effectiveness ............................................................................................... 39 Priority 3: Patient Experience .................................................................................................. 42 Part 3: Review of Quality Performance 2014-15 ...................................................................... 46 3.1 Performance against national priorities .......................................................................... 46 3.2 Other patient safety activity ........................................................................................... 48 3.3 Other effectiveness activity ............................................................................................ 55 3.4 Other patient experience activity ................................................................................... 58 3.5 Workforce factors ......................................................................................................... 65 3.6 Other developments ...................................................................................................... 75
Part 4: Appendices ................................................................................................................. 76
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Appendices
Appendix 1 ............................................................................................................................ 77 Croydon Clinical Commissioning Group Statement to the Directors of Croydon Health Services
NHS Trust on the Annual Quality Account Appendix 2 ............................................................................................................................ 78 Healthwatch Croydon Statement to the Directors of Croydon Health Services NHS Trust on the
Annual Quality Account Appendix 3 ............................................................................................................................ 79 Croydon Overview and Scrutiny Committee Statement to the Directors of Croydon Health
Services NHS Trust on the Annual Quality Account Appendix 4 ............................................................................................................................ 80 Independent Auditors report to the Directors of Croydon Health Services NHS Trust on the
Annual Quality Account Appendix 5 ............................................................................................................................ 83 National Clinical Audit: actions to improve quality Appendix 6 ............................................................................................................................ 89 Local Clinical Audit: actions to improve quality Appendix 7 ............................................................................................................................ 97 National confidential enquiries: actions to improve quality Appendix 8: .......................................................................................................................... 95
MRSA bacteraemia improvement work at CUH 2008 – 2015 Appendix 9: ......................................................................................................................... 96
HAI C.difficile improvement work at CUH 2008 - 2014 Appendix 10: ........................................................................................................................ 97
Patient Safety Alerts 2014-15
Appendix 11: ...................................................................................................................... 100
Glossary
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About the Quality Account
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What is a Quality Account?
The Quality Account is an annual report about the quality of services provided by Croydon Health Services
NHS Trust. The Quality Account is an important way in which we report on quality and show
improvements in the services we deliver to our service users and local communities. The quality of the
services is measured by looking at patient safety, the effectiveness of treatments that patients receive and
patient feedback about the care provided.
What are the requirements of a Quality Account?
The National Health Services (Quality Accounts) Regulations 2010 specify the requirements of Quality
Accounts and these are set out in the Health Act 2009. Amendments were made in 2012, such as the
inclusion of quality indicators according to the Health and Social Care Act 2012. We have used these as a
framework for the production of our Quality Account. Within our Quality Account you can expect to see:
Part 1
A statement on Quality from the Chief Executive
Part 2
Priorities for improvement. These are commitments by the Trust to improve the quality of our care which
we will monitor and report over the year.
Statements about the quality of services provided by the organisation which also allow readers to
compare us against similar organisations.
Part 3
A review of quality performance. This demonstrates how the Trust has performed throughout the year.
Part 4
Stakeholder and external assurance statements. We have reflected the views of patient groups, external
stakeholders and staff to ensure that the account gives an accurate view of the organisation.
How did we produce our Quality Account?
We have used the Department of Health guidance (Quality Account Toolkit) to form the written structure
of the Quality Account.
Patient and Public Voice
Since its launch in September 2012, Listening Into Action has been the Trust’s chosen engagement and
empowerment initiative. It enables staff to identify, lead and deliver change and improvements locally, as
a result of listening to feedback from staff, patients and stakeholders.
We have taken the opportunity to engage with staff and patient representatives throughout the year in
order to inform our key quality priorities for 2015/16. In March 2015 the Trust hosted two listening
events: the first attended by over 60 patients, relatives and members of the Croydon community and the
second attended by our local stakeholders, to hear their views about where the organisation should focus
its attention next, to impact most on patient care and how staff feel about working here.
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Our resulting Quality Experience and Safety Programme (QESP) has been developed to reflect these
priorities and the Care Quality Commission’s key areas which ask the following of our services:
Are they safe?
We aim to protect our service users from physical, psychological or emotional harm
Are they effective?
We aim to meet the needs of our service users and their care is in line with nationally recognised
guidelines. We want our service users to have the best chance of getting better or living
independently
Are they caring?
We aim to treat our service users with compassion, respect and dignity, with care being tailored
to meet their individual needs
Are they responsive to people’s needs?
We aim to provide service users with care and treatment at the right time, without excessive
delay. Listening to our service users and responding in a way that addresses their needs and
concerns.
We aim to continuously have effective leadership in place, governance (both clinical and corporate) and
clinical engagement across all levels of the organisation. We also continue to build an open, fair and
transparent culture that listens and learns from people’s views and experiences to make improvements.
Quality improvement capacity and capability
Improving quality lies at the centre of all we do as a Trust. Our
aim is to deliver excellent integrated care for the people of
Croydon, when and where they need it.
We constantly strive to improve the services we offer by placing
quality at the heart of any planned developments. Therefore, we
monitor quality activity and improvements in order to determine
how well we are doing and report quality outcomes and
information both locally at clinical delivery level and at Board
level.
Improving quality lies
at the centre of all we
do as a Trust. Our aim
is to deliver excellent
integrated care for the
people of Croydon
Trust-wide information relating to safety, effectiveness and
patient experience is analysed and reported via the Board subcommittee structure.
A formal Executive Quality Report is presented bi-monthly to the Board. This offers analysis of
performance across all these areas to inform current state and future developments. Our Director of
Nursing, Midwifery and Allied Health Professionals and Medical Director are the executive leads for
quality and are responsible for keeping the Board informed of quality issues, risks, performance and good
practice.
External review and monitoring also occurs from a variety of stakeholders including NHS Commissioners
and regulators (such as the Care Quality Commission).
Information relating to each of the sections throughout this Quality Account is a true reflection of quality
performance for 2014/15. This includes where things have not gone as planned or where we have made
errors from which we have learned lessons resulting in changes to practice.
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Croydon Health Services NHS Trust is an integrated care organisation providing healthcare in both the
hospital and community setting. Our clinical directorate structure is designed to maximise the benefits of
this for our patients, their families and carers. We have four clinical directorates, each led by a clinical
director (a senior clinician) supported by a senior nurse and a senior operational manager:
•
•
•
•
Adult Care Pathways
Family Services
Critical Care and Surgery
Cancer and Core Functions (such as Radiology and Pharmacy services)
Unless otherwise stated, tables/diagrams throughout this report are Trust-wide and reflect performance
across the Trust’s portfolio of services.
We have mechanisms in place to help us to learn from adverse events, complaints and patient experience
feedback and many examples of this are included throughout the relevant sections.
We recognise that some of the information provided may not be easily understood by people who do not
work in healthcare. So, where necessary, we have provided explanations within a glossary in the
appendix.
At Croydon Health Services NHS Trust we are keen to share information publicly about the quality of our
services and about our continuous improvement work. You will be able to access a copy of our Quality
Account by:
•
•
•
Viewing it on NHS Choices
Viewing it on Croydon Health Services NHS Trust website
Requesting a hard copy from our communications team, who will send you a copy
We hope that you find our Quality Account informative. If it prompts further questions, or you have any
comments about our services, we would like to hear from you.
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Statement of Director’s responsibilities in respect
of the Quality Account
#HelloMyNameIs
Meet the Board of Croydon Health Services
Chairman
Mike Bell
Associate Non Executive Directors
Jamal Butt
Mr Mike Bailey
Non Voting Directors
Michael Burden
Lisa Chesser
Director of HR and Organisational Development
Director of Planning and Informatics
Chief Executive
John Goulston
Non Executive Directors
John Thompson
Louise Cretton Godfrey Allen
Jayne Black Chief Operating Officer and Deputy Chief Executive
Dr James Gillgrass Steven Corbishley
Voting Directors
Azara Mukhtar
Michael Fanning
Director of Finance
Director of Nursing, Midwifery
and Allied Health Professionals
Mr Stephen Ebbs
Medical Director
The directors are required under the Health Act 2009 to prepare a Quality Account for each financial
year. The Department of Health has issued guidance on the form and content of the Annual Quality
Account (in line with the requirements set out in Quality Accounts legislation).
In preparing their Quality Account, directors are required to take steps to assure themselves that:
•
•
•
•
•
the Quality Account presents a balanced picture of the Trust’s performance over the reporting
period;
the performance information reported in the Quality Account is reliable and accurate;
there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to review to confirm
they are working effectively in practice;
the data underpinning the measure of performance reported in the Quality Account is robust
and reliable, conforms to specified data quality standards and prescribed definitions, and is
subject to appropriate scrutiny and review; and
the Quality Account has been prepared in accordance with Department of Health guidance.
The directors confirm to the best of their knowledge and belief that they have complied with the above
requirements in preparing the Quality Account.
By order of the Board
Chair
30 June 2015
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Statement on quality from the Chief Executive
I am pleased to share with you the Quality Account for Croydon Health Services
NHS Trust (CHS) for 2014-15. I hope that you will find this a useful guide to how
the Trust has been working to improve care over the past year and our future
priorities. This quality report is one way we can report on the quality of services
we provide. It looks at whether we are meeting the standards that are set
externally and reviewing whether we have achieved the improvement measures
we set ourselves. The drive for many of these areas of improvement comes from
listening to our patients and their families, our staff, our stakeholders and
working with them to define measures of success.
Croydon Health Services NHS Trust is an Integrated Health Care Trust and since
2010 has been running both hospital and community based services. We want to
make our services as seamless as we can so that patients receive continuous care wherever they are.
As an integrated care organisation our services are based at two hospital sites, Croydon University
Hospital and Purley War Memorial, and 16 community health centres.
We employ 3,640 dedicated staff – with more than a third of staff providing care and support in people’s
homes, in schools and clinics throughout Croydon.
The London Borough of Croydon is made up of one
of the most diverse and deprived areas in the capital
with more than 383,000 local population; having
one of the highest proportions of hard-to-reach
black and minority ethnic groups in South London
and the highest number of looked -after children of
any London borough (around 800).
The second part of this report reflects on how we
have performed in relation to the improvement
priorities we set for 2014-15, these being broken
down into three main areas:
Priority one - Patient and
service users experience
To gain real time feedback to improve patients’ and
service users’ experience.
Priority two - Clinical
effectiveness
To reduce the number of unnecessary hospital admissions and allowing patients to stay in their own
home or in intermediate care bed.
Priority three - Patient safety
To improve on the experience patients and their families have when discharged from hospital, ensuring a
timely and appropriate discharge and with all the equipment and services in place to meet each
individual’s needs.
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In part 3 of this report you will find the results of our performance against key external quality indicators.
This includes whether we have met waiting time targets for our cancer patients and our success at
limiting the number of cases of hospital-acquired infections. In this section of the report there are the
results of our performance against a range of locally developed quality and safety measures, for example,
infections and hospital mortality rates.
Patient and service users’ experience
The results from the 2014-15 inpatient survey (soon to be
published) show that 73% of patient’s felt they were always
treated with respect and dignity, 71% always had confidence and
trust in their doctors, 98% said hospital rooms/wards were very or
fairly clean. Our patients also suggested that we could further
improve by reducing noise on our wards at night, more privacy and
dignity in A&E, and more support from staff to help patients eat
their meals.
In the recent inpatient
survey, 98% of
patients said that
hospital wards were
very or fairly clean
Clinical effectiveness
Each day we see more than 940 adults across our community services, 1,000 patients attend our
outpatient departments, 190 children visit community staff, 100 patients have a surgical procedure, 10
babies are born in our improved maternity unit and up to 400 people use our urgent and emergency care
services.
Our integrated learning disability care, run jointly with Croydon Council, has been the best performing
borough in London for the second year running.
Croydon University Hospital (CUH) Emergency Department has the highest rates of attendances and
emergency admissions per one thousand people in London. This makes our Emergency Department one
of the busiest in the country, seeing up to 100 ambulances a day in the winter months. This is over a 40
per cent rise over the last decade. We were able to achieve 93.78% against the four hour Accident &
Emergency target in 2014-15.
It is with this in mind that I am pleased to say that our business case for a new Emergency Department at
Croydon University Hospital has been approved. The new £21.25 million pound Emergency Department is
planned to open by spring 2017 and will be much bigger than our current facilities.
In March 2015 we began a new campaign, which included the use of innovative social media methods,
to recruit more nurses. Whilst we have increased our staffing levels by employing 150 more nurses than
in 2013, we have also made some fundamental changes to improve our recruitment process including
contact with candidates within 24 hours of receiving an application and interviews being held on a
weekly basis. It is important to recruit staff with the right skills and attitudes for delivering modern
compassionate care; we have therefore set very high assessment criteria for all new applicants and we are
now expanding the campaign to boost recruitment for other healthcare staff.
Patient safety
Last year 1,000 of our clinicians had shared access to electronic patient records through one secure
system. This has improved safety with rapid access to medical histories, reducing the paperwork burden
and has freed up staff to dedicate more time to care. This coming year we are expanding this access
further to include all nursing care plans and assessment, maternity care, critical care, day surgery, and our
main theatres.
We have also been successful in a bid for £969,000 from the nurse technology fund. This will be used to
give our staff working in the community the ability to work wherever they are in Croydon (including in
people’s homes) through secure remote access to patient information. This will enable real-time
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completion of clinical records and will enhance information sharing across colleagues in the community
setting.
I am pleased to say we are the first healthcare provider in the UK to have been awarded level-six
certification from the Hospital Information and Management
Systems Society’s test (HIMSS) for our use of technology to
We are the first healthcare
improve patient care and safety through the implementation of
provider in the UK to have
our electronic patient record (CRS Millennium). This means we
also furthest along the road to being a paperless NHS
been awarded level-six
organisation.
Some of the Trust’s other achievements include the reduction of
debilitating pressure ulcers in the community by 40% through
new multi-disciplinary training programme; the conversion of
two of our elderly wards into ‘Dementia Friendly Zones’; and in
March 2015 we became the first trust in the country to be
awarded Listening into Action accreditation kite mark in
recognition of our staff engagement and empowerment
approach.
certification from the Hospital
Information and Management
Systems Society’s test (HIMSS)
for our use of technology to
improve patient care
This report demonstrates the achievements and the power of working with our partners, our patients,
their families, and all our staff to drive improvements. Over the coming year this work will continue as we
build momentum and focus our efforts for the best interests of our patients and services users of
Croydon Health Services NHS Trust.
I, John Goulston, confirm that to the best of my knowledge all the information in this document is
accurate.
John Goulston
Chief Executive
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Quality improvement priorities for 2015-16
We have identified a series of quality improvement priorities based on the five key areas identified by the
Care Quality Commission (CQC) that reflect the characteristics of services that deliver high-quality care:
•
•
•
•
•
Are services safe?
Are services effective?
Are they caring?
Are they responsive to people’s needs?
Is the organisation well-led?
Over the year ahead, we will be focusing our attentions on the delivery of these quality improvements
across a range of projects. We would however, like to highlight the following projects as key priorities for
2015-16:
Priority 1: Safety
By safe, we mean people are protected from
abuse and avoidable harm
To establish the ‘Sign up to Safety’ programme
and implement actions identified.
Priority 2: Effectiveness
By effective, we mean that people’s care,
treatment and support achieves best
outcomes, promotes a good quality of life
and is based on the best available evidence
Priority 3: Caring
By caring, we mean that staff involve and
treat people with compassion, kindness,
dignity and respect.
Priority 4: Responsive
By responsive, we mean that services are
organised so that they meet people’s needs.
‘Golden Ticket Home’ - patients are
appropriately and safely discharged home from
each ward in a timely manner.
To continue to embed the Quality, Experience
and Safety Programme (QESP) to improve
quality, safety and patient experience practices
into our daily work across the Trust.
To work towards achieving compliance with the
London Quality Standards. To ensure that we
have the right person available at the right time
for patients in our care.
Priority 5: Well-led
By well-led, we mean that the leadership,
management and governance of the
organisation assures the delivery of high
quality person-centred care, supports
learning and innovation, and promotes an
open and fair culture.
Implement any recommendations from the pilot
of the ‘Well-led Framework’ to strengthen our
approach to governing quality.
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Priority 1: Safety
To establish the ‘Sign up to Safety’ programme and implement
actions identified.
What is ‘Sign up to Safety’?
After the publication of the Mid-Staffordshire NHS Foundation Trust public inquiry, the Berwick Report
into patient safety in the NHS, and the Hard Truths report, a range of initiatives are being put in place to
support patient safety improvements in the NHS. A national patient safety campaign ‘Sign up to Safety’
was launched on 24 June 2014, with an ambition of halving avoidable harm in the NHS over the next
three years, and saving 6,000 lives as a result. There are five areas Trusts have to focus on to improve
patient safety, we have set these out below:
•
Put safety first: Commit to reducing avoidable harm in the NHS by half and make public the
goals and plans developed locally
•
Continually learn: Make their organisations more resilient to risks by acting on feedback from
patients and by constantly measuring and monitoring how safe their services are
•
Honesty: Be transparent with people about their progress to tackle patient safety issues and
support staff to be candid with patients and their families if something goes wrong
•
Collaborate: Take a leading role in supporting local collaborative learning, so that
improvements are made across all of the local services that patients use
•
Support: Help people understand why things go wrong and how to put them right. Give
staff the time and support to improve and celebrate the progress.
Our programme aligns with the national priorities for reducing harm which are listed in the table below
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Why this is a priority?
Croydon Health Services NHS Trust ‘Signed up to Safety’ in September 2014, making a number of public
pledges. In 2015-16 the Trust will develop these pledges into a programme of safety work with
measurable goals that we can be held to account for. Our pledges are:
PLEDGE 1- Put safety first
Commit to reduce avoidable harm in the NHS by half and make
public our goals and plans developed locally. We will:
•
•
•
•
•
Promote safe and secure discharge, and look after people in their own home, or close to where
they live rather than having to come into hospital
Launch a sepsis campaign to ensure our staff improve the management of patients with
symptoms of sepsis
Develop a programme to review acute kidney injury
Review all patient deaths, report our findings and take action to improve
Continue work to reduce the number of patients who acquire pressure ulcers and have falls
PLEDGE 2 – Staff continually learn
Make our organisation more resilient to risks, by acting on the
feedback from patients and by constantly measuring and
monitoring how safe our services are. We will:
•
•
•
•
•
•
Actively listen to our patients to see how we can improve and provide ways of user friendly
feedback
Respond promptly to concerns raised and feedback our actions taken
Continue with our executive safety walk rounds and ask patients for their views using the friends
and family test
Share patient stories with Trust Board and at other key meetings
Look at our systems to understand how we can learn from serious incidents, inquests, claims and
complaints
Monitor our internal intelligence and use this for improving and developing services
PLEDGE 3 – Honesty
Be transparent with people about our progress to tackle
patient safety issues and support staff to be candid with
patients and their families if something wrong. We will:
•
•
•
Continue to be open and honest with patients and their families when things go wrong
Seek to strengthen the membership of the Serious Incident Review Group to ensure that all
serious incidents are reviewed by an established multi professional committee
Look to see how we can strengthen involvement of patients in our quality governance activities
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PLEDGE 4 – Collaborate
Take a leading role in supporting local collaborative learning so
that improvements are made across all of the services that
patients use. We will:
•
•
Seek to take every opportunity to share good practice with our partners
Improve communication between the hospital and primary care (GPs) as patients move between
different settings.
PLEDGE 5 – Support
Help people understand why things go wrong and how to put
them right. Give staff the time and support to improve and
celebrate the progress. We will:
•
•
•
•
•
Create a non-blame culture to encourage staff and patients to be able to raise concerns so that
we can put things right quickly
Continue and build upon the Listening into Action (LiA) projects and celebrate success
Provide support and feedback to staff following incidents to look at how we can do things
differently
Hold an annual ‘Croydon Stars’ awards for staff and volunteers to celebrate success
Hold an annual quality event to share good practice
How will performance be measured and monitored?
This priority will be measured through the achievement of key milestones within the set programme and
against project specific outcome measures. For example, for ‘Review all patient deaths, take action to
improve where relevant and report our findings’:
Process measure
Quality measure
The percentage of inpatient
deaths that have been
reviewed for quality of care
provided
Performance Target = 100%.
To have zero avoidable
deaths
Performance Target = Zero
Progress and outcome measures will be monitored by our Patient Safety and Mortality Committee,
reporting to our monthly Quality and Clinical Governance Committee (a sub-committee of the Trust
Board). The first key milestone is for the Trust to finalise the detailed programme and project plans that
support this work by the end of June 2015.
Who is the lead director?
The Medical Director has been assigned as the lead for this priority.
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Priority 2: Effectiveness
To make our discharge process more effective through the
introduction of the ‘Golden Ticket Home’ programme
What is the ‘Golden Ticket Home’?
We will introduce the ‘Golden Ticket Home’ project where one patient from each ward is identified with
a Golden Ticket to be safely discharged by 10.00am each day. By having plans in place this means that
there can be clear communication with the patients, their relatives and carers. This will enable the Trust
to create capacity and reduce delays for incoming patients.
G
Get all inpatients to have a consultant review before 10am
O
One adult patient clinically ready to be discharged by 10am on every
ward
L
Look ahead and book patient transport a day in advance
D
Don’t forget prescriptions to pharmacy by 3pm the day before
E
Every patient should have a completed personal care plan
N
Never let your patient go home inappropriately clothed or in a patient
gown
Why is this a priority?
This is a continuation of the work we started in our Quality Account priorities in 2014-15 on improving
the experience of patients when being discharged from hospital. Whilst there has been an overall
improvement in discharges before 6pm in the evening and every effort taken to ensure people are
appropriately attired, there is more we can do. With the introduction of a nursing whiteboard we can
now ensure that all patients have an expected date of discharge which is identified and reviewed on a
regular basis. This helps the multi-disciplinary team to work together to support the patient’s safe
discharge and ensure that this is achieved in a timely manner.
How will performance be measured and monitored?
This priority will be measured through the number of patients being discharged home before 10am and
the reduction in the number of discharges after lunch. Progress will be monitored by the QESP
Operational Steering Group reporting to the Quality and Oversight Executive Management Board. A
quarterly report on progress against the plan will be presented to our Quality and Clinical Governance
Committee (a sub-committee of the Trust Board).
Who is the lead director?
The Director of Nursing has been assigned as the lead for this priority.
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SPriority 3: Caring
To continue to embed the Quality, Experience and Safety
Programme (QESP) to improve quality, safety and patient
experience practices into our daily work across the Trust.
What is the QESP?
Our Quality, Experience and Safety Programme (QESP) is our blueprint to improve the quality of our
services as evidenced through patient surveys and replaces our Quality Improvement Plan (QIP).
Our Quality Improvement Plan (QIP) set out the key milestones that we had to achieve to hit this
target. This included all of the actions we are taking to address the areas of improvement raised by the
Care Quality Commission’s first inspection in September 2013, as well as NHS-wide lessons from the
Francis Review and the report by Ann Clwyd MP into complaints handling.
This year, we had our progress independently assessed by a leading expert. We also presented the
evidence supporting our improvements (attended by representatives from the CQC, NHS Trust
Development Authority (TDA) and Croydon Healthwatch and where further actions were needed at a
Quality Summit in October 2014.
163 out of 166 (98%) milestones have been delivered, which means that 16 of the 18 projects within the
QIP have been completed. We have expanded the QIP remit to create the Quality, Experience and Safety
Programme (QESP). QESP sets out to drive continued improvements in quality, safety and patient
experience by embedding best practice throughout the Trust.
All improvement actions have been aligned to the five domains that will be assessed by the CQC.
Why is this a priority?
Croydon Health Services NHS Trust is subject to periodic reviews, (both planned and unannounced) by the
Care Quality Commission. The trust is refocusing its internal systems and processes to reflect the new
style inspection regime and the new regulations that came into force on 1 April 2015. In doing this we
will bring a refreshed focus to our on-going improving patient experience work. We set ourselves an
ambitious target to improve our patient experience rating by 10 per cent in two years (by 2015- 2016)
more than twice the national average. We know we are making progress; but equally we know where
we need to work harder still to overcome the challenges we face. The Trust has identified this as priority
this year to ensure that we actively provide good quality care, improve our services and listen to our
service users.
How will performance be measured and monitored?
This priority will be measured through the achievement of key milestones within the set programme, by
improvements in our FFT scores and our performance in the national patient surveys. Progress will be
monitored by the QESP Operational Steering Group reporting to the Quality and Oversight Executive
Management Board. A monthly report on progress against the plan will be presented to our Quality and
Clinical Governance Committee (a sub-committee of the Trust Board).
Who is the lead director?
The Director of Nursing has been assigned as the lead for this priority.
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Priority 4: Responsive
To work towards achieving full compliance with the London
Quality Standards, to ensure that we have the right person
available at the right time for patients in our care.
What are the London Quality Standards?
London Quality Standards (LQS) represent the minimum quality of care that patients attending an
emergency department or who are admitted as an emergency should expect to receive in every acute
hospital in London. Similarly, the maternity services quality standards represent the minimum quality of
care women who give birth should expect to receive in every unit in London.
Why is this a priority?
National data shows that patients admitted as an emergency at the weekend have a significantly
increased risk of dying compared to those admitted on a weekday. This suggested a minimum of 500
lives could be saved every year across London.
To date we have been working towards achieving compliance with the London Quality Standards. We
have so far achieved 69% compliance. This priority is highlighted in the Medical Director’s business plan
for 2015-16.
How will performance be measured and monitored?
This priority will be measured through the form of a refreshed self-assessment against the London Quality
Standards and the percentage compliance being reported to the Quality and Oversight Executive
Management Board. Twice a year a report on progress against the plan will be presented to the Quality
and Clinical Governance Committee (a sub-committee of the Trust Board).
Who is the lead director?
The Medical Director has been assigned as the lead for this priority.
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Priority 5: Well-led
Implement agreed recommendations from the pilot of the Wellled Framework to strengthen our approach to governing
quality.
What is the Well-led Framework?
As a result of failings in leadership identified in Robert Francis' second report of Mid Staffordshire NHS
Foundation Trust, the Trust Development Authority (TDA), Monitor and the Care Quality Commission set
out their intent to work together to assess how well organisations were led. The framework developed by
these regulatory bodies describes four domains with ten high-level questions and a body of ‘good
practice’ outcomes.
This focuses on leadership, management and the governance of organisations to ensure the delivery of
high quality care for patients, support learning and innovation whilst promoting an open and fair culture.
The guidance is universal and applies equally to all NHS provider organisations.
The Well-led Framework asks ten questions across four domains and the guidance describes examples of
good practice behind each question.
Strategy and
planning
Q1 Does the board have a credible strategy to provide high
quality, sustainable services to patients and is there a robust plan
to deliver?
Strategy and
planning
Q2 Is the board sufficiently aware of potential risks to the quality,
sustainability and delivery of current and future services?
Capability and
culture
Q3 Does the board have the skills and capability to lead the
organisation?
Capability and
culture
Q4 Does the board shape an open, transparent and qualityfocused culture?
Capability and
culture
Q5 Does the board help support continuous learning and
development across the organisation?
Process and
structures
Q6 Are there clear roles and accountabilities in relation to board
governance (including quality governance)?
Process and
structures
Q7 Are there clearly defined, well-understood processes for
escalating and resolving issues and managing performance?
Process and
structures
Q8 Does the board actively engage patients, staff, governors and
other key stakeholders on quality, operational and financial
performance?
Measurement
Q9 Is appropriate information on organisational and operational
performance being analysed and challenged?
Measurement
Q10 Is the board assured of the robustness of information?
20
Why is this a priority?
Governance issues are increasing across the healthcare sector. Since 2008, approximately one in four NHS
foundation trusts have been subject to formal regulatory action on at least one occasion, with poor
governance a contributing factor in almost all of these cases. Good governance is essential in addressing
the challenges that the Trust faces with significant financial and operational issues locally. The Board
needs to ensure that their oversight of the quality of care provided by the Trust is robust in the face of
uncertain future income, potential new models of care and resource constraints. Good governance is
essential if we are to continue providing safe, effective, sustainable and high quality care for patients.
Croydon Health Services NHS Trust was one of three pilot sites for implementation of the Well-led
Framework in NHS trusts and will receive a formal report in quarter one 2015. It is likely this will include
recommendations for improvement.
How will performance be measured and monitored?
This priority will be measured through the form of a refreshed self-assessment against the Well-led
Framework following a period of improvement work to address the recommendations from the initial
assessment in April 2015. This will be reported to the Trust Board.
Who is the lead director?
The Chief Executive (supported by the Head of Corporate Governance) has been assigned as the lead for
this priority.
What have we done so far
•
•
•
•
•
•
•
•
•
A new governance structure has been developed, agreed by both the Executive Management
Board and the Trust Board (part 2 on 15 April 2015) and implemented.
A Financial Recovery Board (FRB) has been established. This will meet weekly on a Tuesday with
an agenda alternating between Income and Expenditure. The FRB replaces the Turnaround
Board. The Chief Executive Officer (CEO) will chair the FRB and membership will include the
Executive Directors, the Assistant Directors of Operations (ADOs) and the Director of Estates. The
Director of Finance will manage the agenda. However, once financial stability and recovery is
reached, membership will be reduced to the Executive Directors only. Issues and reports from
the FRBs will be escalated to the Finance and Performance Committee of the Board for
information, assurance and action.
Four Executive Management Boards (EMBs) have been established. These will meet each
Thursday between 0900 and 10.30 on a rotational basis. These will replace the original
Executive Management Board that used to meet monthly. The new EMBs are as follows:
Resilience EMB. This will be chaired by the CEO and the agenda managed by the Chief
Operating Officer (COO).
Informatics EMB. This will be chaired by the CEO and the agenda managed by the Director of
Planning and Information.
Business Planning EMB. This will be chaired by the CEO and the agenda managed by the
Director of Planning and Information.
Quality and Oversight EMB. This will be chaired by the CEO and the agenda managed by the
Director of Nursing, Midwifery and AHPs.
Membership of the EMBs will include the Clinical Directors (CDs) with alternates if they cannot
attend.
The EMBs will act as gate keepers for the escalation of information to the Board's assurance
Committees or the Trust Board itself for information assurance and action. Some flexibility with
the agendas will be required to ensure papers are prepared in time for the Board's Assurance
Committees, it is anticipated that this is most likely to occur between the Quality and Oversight
EMB and the Quality and Clinical Governance Committee.
21
Statements of assurance from the Board
The following statements are mandated by regulation for inclusion in all NHS Quality Accounts:
•
•
•
•
•
•
•
•
Review of services
Participation in clinical audits
Participation in clinical research
Use of the Commissioning for Quality and Innovation (CQUIN) framework
Statements from the Care Quality Commission
Data quality
Information Governance Toolkit attainment level
NHS Outcomes Framework - indicators
Review of Services
Throughout 2014-15 we have been privileged to continue to provide services to the people of Croydon
whether in their own home, at one of our community facilities or at one of our hospitals.
During 2014-15 the services NHS Trust provided and/or sub-contracted 53 NHS services.
Services NHS Trust has reviewed all the data available to them on the quality of care of 100% of these
services. The Trust reviews indicators of quality using a dashboard and reports so that performance can
be analysed on a monthly basis. This enables services to identify priorities and actions needed to deliver
improvements.
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 Croydon Health Services NHS Trust for 2014-15.
Participation in national clinical audits and national confidential enquiries
Participation in national clinical audits and confidential enquiries enables us to benchmark the quality of
the services that we provide against other NHS Trusts, and hence highlight best practice in providing high
quality patient care and drive continuous improvement across our services.
During 2014-15, 37 national clinical audits and four national confidential enquiries covered NHS services
that Croydon Health Services NHS Trust provides.
During that period Croydon Health Services NHS Trust participated in 97% national clinical audits and
100% national confidential enquiries of which it was eligible to participate in. Croydon Health Services
NHS Trust also undertook 50 local clinical audits in 2014/15.
The national clinical audits and national confidential enquiries that Croydon Health Services NHS Trust
was eligible to participate in during 2014/15 are listed on the next page.
The national clinical audits and national confidential enquiries that Croydon Health Services NHS Trust
participated in, and for which data collection was completed during 2014/15, are listed below 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.
22
National clinical audits and participation
Title
Number
of cases
% submitted
Acute Coronary Syndrome or Acute Myocardial
Infarction (MINAP)
76
In progress
Adult Community Acquired Pneumonia
In
Progress
In progress
British Society for Clinical Neurophysiology
(BSCN) and Association of Neurophysiological
Scientists (ANS) Standards for Ulnar Neuropathy
at Elbow (UNE) testing
5
100%
Bowel Cancer
117
100%
Cardiac Rhythm Management
170
In progress
Case Mix Programme
183
In progress
Coronary Angioplasty/ National Audit of PCI
433
In progress
National Diabetes Foot care Audit
In
Progress
In progress
National Pregnancy in Diabetes Audit
20
100%
National Diabetes Audit
In
Progress
In progress
Diabetes Paediatric (NPDA)
181
100%
Elective Surgery (National PROMS Programme) –
Did not participate in*
Epilepsy-12
15
75%
Falls and Fragility, Fractures Audit Programme
223
In progress
Fitting Child (Care in the emergency department)
28
100%
Head and Neck Cancer
In
progress
In progress
Inflammatory Bowel Disease (IBD) Programme
24
100%
National Hip Fracture Database
IBD- Biologics
23
Lung Cancer (NLCA)
121
92%
Major Trauma: The Trauma Audit and Research
Network (TARN)
186
64%
Maternal, Newborn and Infant Clinical Outcome
Review Programme (MBRRACE-UK)
31
100%
Mental Health (Care in Emergency Department)
50
100%
National Audit of Intermediate Care
12
**
National Cardiac Arrest Audit (NCAA)
3
3.70%
Did not
participate
National Chronic Obstructive Pulmonary Disease
(COPD) Audit Programme – Secondary Care work
stream
103
100%
National Chronic Obstructive Pulmonary Disease
(COPD) Audit Programme –Pulmonary
In
progress
In progress
National Comparative Audit of Blood Transfusion
228
Red cell trace cycle
33
100%
Sickle cell disease audit
100%
Patient blood management in scheduled surgery
In
progress
National Emergency Laparotomy Audit
107
93%
National Heart Failure Audit
308
100%
National Joint Registry
54
In progress
National Prostate Cancer Audit
203
In progress
Neonatal Intensive and Special Care (NNAP)
474
100%
Oesophago-gastric Cancer (NAOGC)
93
100%
Older People (Care in the Emergency
Department)
61
100%
Pleural Procedures
8
100%
Rheumatoid and Early Inflammatory Arthritis
In progress
In progress
Clinician/Patient Baseline
138
Clinician/Patient Follow up
115
24
Sentinel Stroke National Audit Programme Organisational
1
100%
Sentinel Stroke National Audit Programme Clinical Audit
287
In progress
**no min/max/expected cases specified, National Audit of Intermediate Care. Paperwork for audit was mislaid which delayed the
start of our data submission resulting in lower rates of participation. The organisational audit was fully completed
National Confidential Enquiries
Title
Number
of cases
% submitted
Sepsis
3
100%
Gastro-intestinal Haemorrhage
5
100%
Lower Limb Amputation
3
100%
Tracheostomy Care
11
100%
The reports of 24 national clinical audits were reviewed in 2014-15 and Croydon Health Services NHS
Trust intends to take action to improve the quality of healthcare provided. These actions are listed in
appendix 5 for each area.
The reports of 50 local clinical audits were reviewed by the provider in 2014/15 and Croydon Health
Services NHS Trust intends to take the action to improve the quality of healthcare provided. These are
listed in appendix 6 for each area.
Participation in clinical research
Research is a core part of the NHS, enabling it to improve the current and future health of the people it
serves. ‘Clinical research’ means research that received a favourable opinion from a research ethics
committee.
The number of patients receiving NHS services provided, or sub-contracted, by Croydon Health Services
NHS Trust in 2014/15, that were recruited during that period, to participate in research approved by a
research ethics committee was 505. (Data taken from the Clinical Research Network (CLRN) registered
file).
Participation in clinical research demonstrates our commitment to improving the quality of care we offer
and to making our contribution to wider health improvement. Our clinical staff stay abreast of the latest
possible treatments, and active participation in research can lead to successful patient outcomes.
In 2014/15, 65 clinical research studies were being conducted in the Trust; 49 of which were funded by
the CLRN. 18 studies concluded by March 2014 of which 44% were completed as designed within the
agreed time and to the agreed recruitment target. This is being revised for 2015 /16 in order to best
reflect ambition verses reality of setting high recruitment figures at the start of a clinical trial.
During 2014/15, we approved nine studies, of which five were supported by the CLRN. The research
applications funded by the CLRN are approved by the CLRN cluster office based at Guys and St Thomas’
25
Hospital, which went live in November 2014. This was set up to increase the speed of the process for
gaining local approvals for studies.
There were 57 clinical staff participating in research
approved by the research ethics committee at Croydon
Health Services NHS Trust during 2014/15. 45% of these
were Research Passport Personnel supporting the research
studies. These staff participated in research covering 11
specialties.
In October 2014 the hospital outpatient treatments clinic
and the Research and Development team completed the
first year on the EU funded WELCOME study. The team and
consortium partners presented their first year’s findings to
the project officer in Brussels and we are pleased to report
that we received a ‘good progress’ assessment, with the
project achieving most of its objectives and technical goals
for the period with minor deviations. This ensures the
second tranche of monies will be released to the Trust for
work on the second year of this project.
In the last three years,
81 publications have
resulted from our
involvement in research,
showing our commitment
to transparency and desire
to improve patient
outcomes and experience
The neonatal team was also successful in a grant application to South West London Academic, Health
and Social Care System where they were awarded £3,380. This will fund the ‘Use of Bike (Red) Light for
Difficult Intravenous Access in Neonates and Infants (BELIEVE) the pilot study is to confirm non-inferiority
of red LED lights for success in difficult IV access of neonates; assess feasibility of roll-out of the LED lights
which could ultimately reduce rates of infection on neonatal units, save cost and make devices to aid
cannulation more accessible and improve success of cannulation of neonates with difficult IV access, an
issue which often significantly compromises their care.
Also in the last three years, 81 publications have resulted from our involvement in research, which shows
our commitment to transparency and desire to improve patient outcomes and experience across the NHS.
Use of the Commissioning for Quality and Innovation (CQUIN) framework
Commissioners hold a health budget for the Croydon population and decide how to spend it on health
care services (in both the hospital and community setting) such as those provided by Croydon Health
Services NHS Trust. Our local commissioners (Croydon Clinical Commissioning Group) and NHS England
set us annual goals based on quality and innovation in order to bring health gains for patients. This
system is called the CQUIN payment framework.
A proportion of Croydon Health Services NHS Trust income in 2014/15 was conditional on achieving
CQUIN goals agreed between Croydon Health Services NHS Trust and any person or body they entered
into a contract, agreement or arrangement with for the provision of NHS services, through the
Commissioning for Quality and Innovation payment framework.
For 2014/15 we are on target to achieve over 95% of our CQUIN income from Croydon Clinical
Commissioning Group (CCG) and 100% NHS England; a list of our CQUIN goals for 2014-15 is included
in appendix 10.
Further details of the agreed goals for 2015-16 are available on request from the Trust from
comms@croydonhealth.nhs.uk
26
Statements from the Care Quality Commission (CQC)
The Trust is governed by a regulatory framework that requires healthcare providers to be registered with
the Care Quality Commission (CQC) and therefore licensed to provide health services.
Croydon Health Services NHS Trust is required to register with the CQC its current registration status is
‘registered with no conditions’. Croydon Health Services NHS Trust has the following conditions on
registration ‘none’. The CQC has not taken enforcement action against Croydon Health Services NHS
Trust during 2014-15.
The Care Quality Commission has a statutory duty to assess the performance of healthcare organisations,
providing assurance to the public about the quality of care through a system of monitoring. The CQC
assessors and inspectors frequently review all available information and intelligence they hold about
trusts, including Croydon Health Services NHS Trust.
Croydon Health Services NHS Trust has not participated in any special reviews or investigations by the
CQC during the reporting period. Croydon Health Services NHS Trust is subject to periodic reviews by the
Care Quality Commission, with the last review carried out on the 17-19 September 2013.
As one of the first wave trusts to undergo the new style CQC reviews introduced in 2013, the Trust chose
at that time not to be given a rating for the 2013 inspection. This review focused on the services at
Croydon University Hospital only. The CQC’s assessment following that review was that Croydon
University Hospital was not meeting all of the standards assessed, with a number of compliance actions
that the hospital must take to improve. Croydon Health Services NHS Trust developed and implemented
a comprehensive action plan to address the ‘must do’ points made in the CQC’s assessment.
Croydon Health Services NHS Trust has made the following progress by the 31 March 2015 in taking such
action:
•
Improved arrangements between Croydon University Hospital Emergency Department and the
Urgent Care Centre (managed by Virgin Care).
o
o
o
o
•
A formal handover procedure is in place to safely transfer patients from the Urgent Care
Centre through to the Emergency Department, which requires the receiving clinician to
sign and formally take over duty of care
A fortnightly joint governance meeting is held to enable collaborative working practices
The Urgent Care Centre now routinely provides information to inform the management
of patient flow through the department and enable the services work together to
safeguard patients and maintain oversight of potential service pressures
Croydon Health Services Foundation Year 2 doctors now spend one week on rotation
into the Urgent Care Centre which has built an improved understanding of the Urgent
Care service, strengthened relationships and added an educational experience for the
junior members of the Emergency Department Team
Improved staffing levels to provide care in the older people’s wards
o
In May 2014 the Trust approved an additional £2.4 million allocation for ward staffing to
achieve 60:40 nurses to healthcare assistant ratio
27
•
Reduced the number of discharges in the evening (especially for older people)
o
•
Improvements made to Outpatients to reduce waits, ensure enough seating is available and put
in place mechanisms for informing patients when there is a delay
o
o
o
o
o
•
Hospital internal data shows an overall improvement with 72% of all patients being
discharged before 6pm. Further work to improve hospital discharge will continue into
2015/16 with our Golden Ticket Home and Home before Lunch initiatives
Refurbishment of the fracture clinic
Communication boards which are updated every 15 minutes with information about
waiting times
Customer care training has been completed by staff
A new appointments leaflet introduced in March 2015
‘Text reminder’ service implemented, resulting in a reduction in the number of missed
appointments
Increased our internal monitoring of the use of care plans
o
o
98.7% of patients admitted to an inpatient ward had care plans in place to address their
care needs
As part of the Trust’s on-going programme to enhance the electronic patient record a
number of the nursing assessment care plans have now been integrated within the CRS
Millennium system. This new innovation will see nurses alerted where patient care plans
have not been completed in a timely manner
These actions in 2014-15 were monitored as part of the Trust’s Quality Improvement Plan, and will
continue to be monitored through the new QESP.
The Trust will be inspected for both community and hospital services in June 2015 and will receive a
rating from the CQC which we will display in our premises and on our website.
You can find out more about the CQC standards at www.cqc.org.uk
Other external quality assurance visits in 2014-15
These have been carried out by:
•
•
•
•
•
•
•
•
•
Accreditation by the Joint Advisory Group on Gastro Intestinal Endoscopy (Deferred in Apr 2014
and achieved in Dec 2014)
Macmillan Quality Environment Mark (May 2014)
SGS Medical Devices Audit (July 2014)
East and South East England Specialist Pharmacy Services (Aug 2014)
Clinical Pathology Accreditation for Biochemistry (Sept 2014)
Clinical Pathology Accreditation for Haematology (Oct 2014)
Urgent and Emergency Care Peer Review – London Quality Standards (Nov 2014)
Clinical Pathology Accreditation for Microbiology (Dec 2014)
NHS England External Peer Review on the Cancer E-prescribing System (Jan 2015)
28
Data quality
Good quality information is both accurate and up to date. Good quality information also underpins the
effective delivery of improvements to the quality of patient care and the effective use of resources. It is
thus essential to the Trust in its task of ensuring value for money for the taxpayers
Croydon Health Services NHS Trust routinely undertakes the following actions to improve data quality:
•
•
Reviews data completeness of, among others, General Medical Practice code, NHS Number and
ethnic coding
Verifies attribution of correct GP Practice code and Clinical Commissioning Group to individual
patients via the national register (SPINE)
By validating these metrics we ensure that personal data held by the Trust’s systems is accurate and in
keeping with the Data Protection Act. Furthermore it prevents the formation of duplicate records,
ensuring the safety of patients and enabling high quality care.
Croydon Health Services NHS Trust was not subject to the Payment by Results clinical coding audit during
2014/15 by the Audit Commission.
Croydon Health Services NHS Trust submitted records during 2014-15 to the Secondary Uses Services for
inclusion in the Hospital Episode Statistics, which are included in the latest published data.
The percentage of records in the published data which included the patient’s valid NHS number was:
•
•
•
97.2% for admitted patient care
97.3% for outpatient care
96.0% for accident and emergency care
The percentage of records in the published data which included the patient’s valid General Medical
Practice Code was:
•
•
•
97.2% for admitted patient care
97.1% for outpatient care
97.2% for accident and emergency care
Information Governance Toolkit attainment levels
In line with all NHS organisations, the Trust is required to self-assess against a variety of standards
contained within the Information Governance Toolkit, relating to the creation, storage, management,
security and quality of information.
Croydon Health Services NHS Trust score for 2014-15 for Information Quality and Records Management
assessed using the Information Governance Toolkit was 73%- Not Satisfactory. The requirement is to
achieve 80% and the Trust has put in place an action plan to improve the performance to achieve level 2.
The Trust is committed to ensuring that its information is managed to the highest standards and in
accordance with the Health and Social Care Act 2008, Care Standards Act 2000, The Data Protection Act
1998, The Freedom of Information Act 2000, Central Government policies and guidance from the
Information Commissioner’s Office.
The Trust complies with the Information Commissioner’s Office checklist for reporting, managing and
investigating information governance incidents. The Trust declared three serious incidents involving
information governance breaches in 2014-15. The checklist covers the reporting arrangements and
describes the actions that need to be taken in terms of communication and follow up.
29
The Trust was visited by staff from the Information Commissioner’s Office (ICO) in March 2014. This
followed a review of incidents reported to the ICO by the Trust. The ICO reviewed the Trust’s practices in
relation to information risk management. Although no significant weaknesses in control were uncovered,
the report made 18 recommendations for improvement. Action in respect of 9 of these recommendations
is completed, and progress on the remaining actions is monitored and reported to the Trust’s Information
Governance Committee.
NHS Outcomes Framework - indicators
The NHS Outcomes Framework 2014-15 set out high-level national outcomes, which the NHS should be
aiming to improve. The framework provides indicators which have been chosen to measure these
outcomes. An overview of the indicators is provided.
It is important to note that whilst these indicators must be included in the Quality Accounts the most
recent national data available for the reporting period is not always for the most recent financial year.
Where this is the case the time period used is noted.
30
Figure 2: Mandated Indicators
31
32
33
Review of quality priorities 2014-15
This section demonstrates the Trust’s achievements throughout 2014-15 in the areas of patient
safety, clinical effectiveness and patient experience. Performance against the priorities in our
2013-14 Quality Account is included in each section. (numbering reflects references in the
Quality Account 2013-14)
3 .1
Quality improvement priorities 2014-15
Priority 1
To improve the experience of discharge from
hospital for patients, their families and carers, in
particular to ensure a timely discharge from
hospital, appropriately attired and with all
equipment and services in place to meet the needs
of the individual
Partially
met
Priority 2
To reduce the number of unnecessary hospital
admissions to allow patients to stay in their own
homes or intermediate care beds
Met
Priority 3
Improve patient experience across the Trust as
measured by real-time patient feedback, through
fostering a culture of continuous improvement
Met
Priority 1: Safety
To improve the experience of discharge from hospital for
patients, their families and carers, in particular to ensure a
timely discharge from hospital, appropriately attired and with
all equipment and services in place to meet the needs of the
individual.
Our results for timely discharge from hospital with all equipment and
services in place:
In October 2014, Purley 3 ward used the ‘Home for lunch’ initiative to successfully get 83% of patients
home for lunch, this is compared to 20% home for lunch and 32% home by 3pm in the previous year.
This work built on the foundations put in place by the Wave 1 LiA Discharge Medication team in June
2013 and included:
•
•
Working with our estates team to create a patient-centred discharge lounge, with an improved
environment (painting, replaced the doors to the lounge, redecorated toilet facilities, and
repaired radiator, cleaned windows) and therefore improved the patient experience on leaving
hospital.
Improved meals in the lounge with hot meals now available and a volunteer to provide assistance
34
•
•
Improved documentation on the electronic patient record for patients in the lounge to enable all
of their care to be recorded and staff to have access to relevant and important information up
until the point of discharge
A new large screen television installed for guests.
The ‘Home for lunch’ principles were embedded on the pilot wards by:
•
•
•
•
•
•
•
•
Introducing ‘huddles’ - short informal meetings so that ward staff are aware of which patients
are going home and what needs to be done to facilitate this
Introducing a patient communication sheet/questionnaire so that patients are aware of their
expected date of discharge and have the opportunity to raise questions prior to discharge
Introducing coloured magnets to add to white board to
identify early discharge patients so that staff are aware
In October 2014, Purley 3
of what patients will be discharged home for lunch
Organising medicine prepacks and provided information
ward used the ‘Home for
to prescribers on what medications are available on the
lunch’ initiative to
ward, negating the need for some discharge medications
successfully get 83% of
to be requested from the dispensary
patients home before
Improving pharmacy support for the lounge
lunchtime
Improving the portering service in the discharge lounge
Earlier phlebotomist rounds were introduced so that
patients requiring a blood test on the day of discharge
will get their results earlier, facilitating early discharge
The data displayed below summarises the actual discharge times as captured from the Trust’s
electronic patient record system (CRS Millennium) from January 2014 through to January 2015
inclusive for:
o All patients
o All patients 65+
o All patients on Elderly Care wards (Wandle 1, 2 and 3 and Queens 3)
Factors to be considered when looking at this data:
•
•
•
•
Discharge times recorded may differ from the actual time of discharge (unless the discharge time
is specifically entered, the data entry time is recorded as a time of discharge). This may account
for a number of patients recorded as discharged throughout the night
The discharge times include patients discharged directly from the wards and via the discharge
lounge (which is open until 8pm)
Patient choice of an evening discharge - particularly if family members/carers are collecting them
or need to be at home prior to them arriving
Patients who died during their admission have been excluded
35
Overall discharge performance by percentage Jan 2014 to Jan 2015:
Chart 1: Percentage of patients discharged by 18:00
% Patients 65+
discharged by 6PM
% Patients (all ages)
discharged by 6PM
201401
201402
201403
201404
201405
201406
201407
201408
201409
201410
201411
201412
201501
201502
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
% Patients on Elderly
Care wards discharged by
6PM
The chart below demonstrates the percentage of patients that as an organisation we discharge before
6pm. On a daily basis the organisation discharges approximately 80 patients per day from our inpatient
bed base. The graph demonstrates that on average, 72% of those required discharges take place before
6pm (approximately 58 patients). The remaining 28% are discharged after 6pm, with the majority of
these patients being discharged before 8pm.
The actual discharge improvements before 6pm that we have seen in the past year within the specified
categories are listed below:
•
•
•
Elderly Care wards = 5% improvement (82% to 87%)
Patients 65+ =8% improvement (67% to 75%)
All patients = 4% improvement (67% to 71%)
Trust discharge profile from inpatient bed base over 12 months:
14%
35%
87%
In summary there has been an overall improvement in the number of patients discharged before 6pm in
2014/15 and looking at the monthly breakdown by hour from Elderly Care wards the numbers of
patients recorded as discharged after 6pm are very small.
36
Areas for further work
Whilst we are discharging patients past 6pm in the evening in some cases, over 90% of the time our
patients are all discharged before 8pm. There is always the potential for our patients to be discharged
later in the day owing to the nature of our peaks in activity on a day to day basis. It must be also
recognised that the organisation’s discharge lounge remains open till 8pm on a daily basis in order to
safely and sustainably manage this flow and appropriate discharge of these patients.
Our focus now is on moving all of our afternoon discharges into the morning. This, in turn, will further
support the reduction in discharges past 6pm.
In addition, there are long term plans to relocate the lounge to provide a larger facility and to extend this
support to the outpatients department for patients leaving the hospital using hospital transport.
Our results on being discharged in appropriate attire
An audit was commenced by the Discharge Lounge to identify those people who were brought to the
lounge inappropriately dressed. This was defined as attending the Discharge Lounge:
•
•
•
•
In their own nightwear
In hospital nightwear
Not having a full set of clothing suitable for the weather
The audit period was April-December 2014.
During the audit period 6,458 patients were discharged from the discharge lounge. Of those, 278 (4.3%)
were deemed to not be appropriately dressed.
Number of patients arriving in the discharge lounge in nightwear
Number of patients in night wear April-Dec 2014
45
40
35
30
25
20
15
10
5
0
The Red Cross provided clothing for 188 (68%) of the patients. Attempts were made to resolve this issue
for all in appropriately dressed patients. In total 55 patients (20%) declined clothes and solution could not
be delivered for 35 patients (12.5%). Of the total discharge lounge attendees 1.4 % (n=90) were
discharged inappropriately dressed, of which 0.85% were through the patient’s own choice. To help
remedy this we increased the availability of clothes in the Red Cross store, so that patients are never
discharged and sent home inappropriately dressed.
37
How the situation was resolved April-Dec 2014
30
25
20
Red Cross 15
Patient refused
10
Unable to resolve
5
0
Areas for further work
Although the numbers are relatively low, it remains unacceptable for patients to leave the hospital
inappropriately dressed. In 2015-16 the Trust will:
•
•
•
Deliver on-going discharge planning training with the Red Cross providing a session to raise
awareness of their services, including providing clothes for patients
A&E liaison to have a small selection of clothes provided by the Red Cross, to ensure available at
the weekends
Continue to raise awareness of the clothing store and advertise it via posters in all in-patient
wards and departments
38
Priority 2: Clinical Effectiveness
To reduce the number of unnecessary hospital admissions to
allow patients to stay in their own home or in intermediate
care beds.
Our results
Redesigned the Single Point of Access service to become a Single Point of Assessment to enable all
community health services referrals to be dealt with by one team.
Increased the use of the specialist team of doctors and nurses
(within the Rapid Response Service) responding quickly to those
who have become unwell at home, to avoid the need for them
to come to hospital.
Single Point of Assessment (SPOA)
The Trust has built on the existing Single Point of Referral (SPOR)
service to become a Single Point of Assessment (SPOA) for
Community Health Services.
The Single Point of
Assessment for
community health
services receives more
than 2000 referrals
per calendar month
The service consists of administrative support and two clinicians
who assist with advice and support. The clinicians are
experienced nurses who have expert knowledge of community
services.
The setup of the service allows GPs and other health professionals to speak with an experienced
community nurse who is be able to advise on the availability of community health and social services that
may be appropriate for individual patients, ensuring they are referred to the most appropriate service.
This team now receive all referrals for community services; receiving in excess of 2,000 referrals per
calendar month.
39
Rapid Response Service
The Rapid Response service is a 24hr per day, 7 days per week service which is delivered by a
multidisciplinary team of healthcare professionals including nurses, occupational therapists and
physiotherapists. The team is able to provide a comprehensive, patient-centred assessment within two
hours of referral for people in their own homes. This reduces the need to attend a hospital either by
direct GP referral or attendance at an emergency department. The team is also able to support early
discharge from hospital by responding to referrals within two hours.
In 2014/15 the team has been able to support four out of every five referrals to the service at the
patient’s home or in an intermediate care bed. This means approximately 96 patients per calendar month
have not needed to be admitted to hospital. The team responded to 95% of all patients within two hours
of receiving a referral.
All patients who use the Rapid Response Service are monitored post-discharge; the service achieves low
levels of hospital admission within seven days of discharge (on average only 6% of patients are admitted
to hospital within seven days).
This success has been achieved through increasing the scope of care the team are able to deliver within
the community setting and the redesign of pathways to obtain specialist investigations that cannot be
undertaken outside of a hospital setting.
The clinical team members:
•
•
•
Administer sub-cutaneous fluids and intravenous antibiotics to patients in their own home.
Provide additional input needed to manage patients in their own homes, including therapy
assessment, pharmacy support, or where necessary community geriatrician input.
Are able to refer patients directly into ambulatory care and the Acute Care of the Elderly Service
(ACE) at Croydon University Hospital for investigations that cannot be undertaken in the
community setting.
Areas for further work
As commissioners of local health services, Croydon Clinical Commissioning Group (CCG) is responsible for
planning the right services to meet the needs of local people, buying local health services including
community health care and hospital services, and checking that the services are delivering the best
possible care and treatment for those who need them.
Croydon CCG has agreed funding for an additional three senior nurses and a speech and language
therapist to work within the team from 2015-16. This additional resource will have a specific focus to
40
support the nursing and care home settings across Croydon with an emphasis on avoidance of hospital
admissions from care homes.
Intermediate care beds
This past year has seen an increase in the number of intermediate care beds available within Croydon
(from 6 to 12). Intermediate care beds are used to support people with complex health needs which
cannot be adequately managed within their own homes but they do not require the medical facilities of a
hospital. The beds have a primary focus on rehabilitation and re-ablement. These facilities can be used for
either:
• Step-up care – to avoid admission to hospital where it is more appropriate to treat people
closer to their home and family support; or
• Step-down care - for a rehabilitation programme, to enable people to maximize their potential
re-ablement after an acute illness and to continue living in their own home safely.
Over the winter months Croydon CCG increased the number
of Intermediate Care beds, opening an additional eight beds,
to help with increased demand for services in this period.
These beds were used to support both step-up, and stepdown care.
Areas for further work
The Trust meets regularly with Croydon CCG to discuss
progress, listen to feedback and work collaboratively to
develop new pathways of care which will continue to
transform community services in Croydon and deliver the
benefits of the Trust being an integrated care organisation.
The Trust launched a
collaborative learning
programme with London
Ambulance Service that
will see 60 paramedics
spending a full day
working with the Rapid
Response Team.
The service has close partnership working with the London
Ambulance Services through weekly rapid response meetings.
This enables all referrals from London Ambulance Service (LAS) to be discussed and the opportunity to
feed back on their experiences of working with our services, to help us continue to improve.
The Trust launched a collaborative learning programme with LAS in March 2015 that will see each of the
60 paramedics that work in the Croydon area spending a full day working with the Rapid Response Team
and new members within the team having the opportunity to spend a day with LAS crews. In the short
time since starting the programme, referrals to the Rapid Response Team from LAS have increased.
41
Priority 3: Patient experience
42
Improve patient experience across the Trust as measured by
real-time patient feedback through fostering a culture of
continuous improvement.
The views of our patients and staff are very important to us. We spend a lot of time collecting and
responding to information we receive about our services from our patients and staff. We receive
feedback through a number of methods including surveys, patient stories and patient experience trackers,
all of which provide us with vital information on how to improve. We had some fantastic engagement
this year with our local stakeholders and we will continue to put a major focus on what matters most to
our patients in the coming year.
The quality improvement plan 2014-15 identified a number of actions to improve patient experience and
these are summarised below. Patients, visitors and staff should be able to see illustrations and images of
staff uniforms through a range of products and at different locations. To achieve this we have:
•
•
•
•
Created a new inpatient welcome leaflet, wall posters, pop-up stands and new meal-tray liners
to show updated images of different uniforms that they will see as they walk around the Trust,
making our healthcare professionals
more visible
Issued our matrons with new red
uniforms; this has created a highly
visible presence of nurse leadership
at ward and department level
Set up ‘Meet the Matron’ sessions.
These are held on a regular basis for
patients and visitors to have open
discussions with our leadership
team at ward and departmental
level
Introduced ‘Visible Wednesdays’; an
initiative for additional senior nurse
leaders in the organisation to work
alongside front-line staff in the
clinical areas, wearing the same red
uniforms. This includes the Director
of Nursing and his deputy
Patients to receive appropriate and timely analgesia, to be reassessed and escalated if necessary.
To achieve this we have:
•
•
•
•
Set up an Acute Pain Task Force Group which implemented a standardised pain assessment tool
to be used across hospital services.
Developed patient-facing posters which were positioned in each cubicle in the emergency
department to promote good pain management; this includes a visual summary of pain
assessments using layman’s terms for ease of understanding.
Used our patient monitoring system (Vital Pac) to record daily pain scores to ensure timely
assessment and administration of pain medication and reassessment, in line with our protocols
for pain management. This has increased focus on pain relief in our emergency department
observation ward and as a direct result of patient feedback received.
Updated our matron’s quality rounds to include prompts to check the effectiveness of pain
management with our inpatients.
43
•
•
•
•
•
•
For front-line staff to wear additional name badges which promotes friendly communication
All front-line staff have been provided with a name badge with large font which promotes the
national campaign #hellomynameis, which the Trust has now widely adopted.
For patients to be offered a comfort pack upon admission to hospital
We have made available hotel services-type comfort packs for inpatients which include shampoo,
shower gel, manicure sets, eye masks and earplugs. These are advertised to patients in the ward
welcome booklet and promoted on notices in bathrooms, with each ward now having a
dedicated housekeeper who supports and promotes them as part of their duties
Welcome and ward information leaflet to be given to all inpatients
We have produced a welcome booklet called “Your stay at Croydon University Hospital”. The
booklet contains information about our staff and their roles, food and mealtimes, visiting,
keeping wards quiet at night, hand hygiene, medication, spiritual care, discharge planning and
how to raise concerns or make a complaint. This information was replicated in the new tray liners
updated in 2014 which are used with every patient tray at meal times.
Inpatient Survey
•
Following the publication of the full national data for the CQC’s Inpatient Survey 2014, the
following represents an analysis of how Croydon Health Services scores compare regionally,
nationally and with our scores last year. It should be noted that this is an analysis of the data as it
has been presented by the CQC and tabulated by the NHS TDA. It is not intended to have the
same level of granularity or insight as the findings from the data made available to the Trust by
Picker, who had conducted the survey on our behalf. This comparison only relates to
organisations that supply acute services.
Key points
•
•
•
•
•
The Trust has not significantly fallen on any question score in the 2014 inpatients survey
from our results in the 2013 survey.
The Trust is one of only three in London not to have a significant fall in any of the
survey’s questions from 2013 to 2014.
The Trust is one of only two Trusts in London to improve its ‘overall satisfaction’ score.
The Trust’s ‘overall satisfaction’ score is now at the average level for non-FT Trusts in
London at 7.7 out of 10, and only 0.2 points below the average score for all London
acute Trusts.
Despite these improvements, the Trust has a number of outstanding challenges to
address. It scored in the lowest 20% of Trusts nationally on 22 questions, and in five of
the broader ‘sections’ of questions.
Further work
The actions that we have developed for the forthcoming year
include:
•
Targeting support from the patient experience team to
areas where the Friends and Family Test is scoring less
than 90%. To include a review of comments with the
ward/department leads, suggesting new ways of
working and improvement actions. New public facing
We had some fantastic
engagement this year
with our local
stakeholders and we will
continue to put a major
focus on what matters
most to our patients in
the coming year.
44
•
•
•
•
•
posters of results and improvement actions on ward/department boards
Monthly ward performance accountability meetings between ward sisters/charge nurses and
Director of Nursing, where FFT will be part of the key indicators for quality.
Continuing with the newly implemented matrons’ observational quality rounds
Housekeepers master-class to refocus the role and the relationship between housekeeper and
patient experience, specifically environment, privacy and dignity, patient mealtimes and seeking
patient feedback.
Exploring the potential to provide patients with IT devices so patients can stream movies, radio
and TV
Informatics department, working with service leads in our community services, to strengthen the
quality metrics to enable more intelligent monitoring in 2015-16
45
Review of Quality Performance 2014-15
3.1 Performance against national priorities
The Trust continues to benchmark positively for a number of indicators, including cancer targets, RTT year
to date, VTE, Harm Free Care, Falls and FFT response rates. The key area for improvement remains
achieving the A&E 4 hour target on a sustainable basis together with reporting of triage times.
Standards
Target
2013/14
2014/15
Meeting the MRSA objective
0
3
1
Clostridium Difficile
17
14
15
RTT Waiting Times for Admitted
Pathways: Percentage within 18 Weeks
90.00%
90.93%
90.45%
RTT Waiting Times for Non-Admitted
Pathways: Percentage within 18 Weeks
95.00%
96.12%
95.89%
RTT Waiting Times for Incomplete
Pathways
92.00%
94.29%
95.67%
Diagnostic Waiting Times for Patients
Waiting Over 6 Weeks for a Diagnostic
Test
1.00%
0.70%
6.49%
A&E 4 Hour Time in Department (All
Types)
95.00%
95.29%
93.78%
Cancer Waits - Referral to First Appt for
Urgent Suspected Cancer (14 days)
Proportion of patients seen within 14 days
of urgent GP referral
93.00%
95.55%
95.85%
Proportion of patients with breast
symptoms seen within 14 days of GP
referral
93.00%
95.26%
97.84%
Cancer Waits - Diagnosis to First
Treatment (31 days)
96.00%
99.68%
97.95%
Cancer Waits - Proportion of patients
receiving subsequent treatment within 31
days (drug)
98.00%
100.00%
100.00%
46
Cancer Waits - Referral to First Appt for
Urgent Suspected Cancer (31 days)
Proportion of patients receiving
subsequent treatment within 31 days
(Surgery)
94.00%
97.95%
100.00%
Cancer Waits - Referral to Treatment for
Urgent Suspected Cancer (62 days)
85.00%
86.90%
87.77%
Methicillin Resistant Staphylococcus Aureus (MRSA)
See section 3.2 Infection Prevention and Control.
Diagnostic waiting times for patients waiting over 6 weeks for a
diagnostic test
Diagnostic tests attract their own, separate, nationally measured diagnostic wait times of six weeks. In
February 2014, the Trust submitted a non-compliant position to the target with 277 patients waiting
longer than the six week standard. Further investigation into the waiting list revealed an accumulation of
approximately 2,200 patients waiting over six weeks for diagnostics. This waiting list had not been visible
due to changes in the computer information system. A recovery programme was put in place and the
service is now on trajectory and meeting in-month performance targets. Due to the rules applied through
18 week referral to treatment time this did have an impact on patient waits for diagnostic tests in 201415 year and was reflected in the end of year performance.
A&E 4 hour time in department (all types)
The Trust did not meet the standard but we did achieve 93.78%. The Trust commissioned the Emergency
Care Intensive Support Team (ECIST) to review the emergency pathway and they have made a number of
recommendations which build upon our existing work programmes.
The challenges to meeting this standard have been compounded by an increase in patient acuity (patients
being sicker and with more complex health needs), leading to a higher conversion rate of over 20%
(greater number of people being admitted to hospital). Some of the other challenges we have faced this
winter has been an increase in attendances which has been our busiest winter and like other trusts in
London we have also had challenges with staffing to ensure that we had the right staff with the right
skills in place.
On the 6 January 2015 the Trust had more patients who required admission into hospital than we had
beds to give them. We quickly called an internal major incident to continue to provide safe care. Calling
a major incident means colleagues in the emergency department, on the wards, our community services
and partners in social care worked together to ease pressure in emergency department.
The Emergency Department Clinical Lead, Dr Kathryn Channing commented,
‘On that day we had filled every space and every corridor in ED with attendances. We immediately did
the best thing to maintain safe services and put in place a series of actions to free-up staff to assess and
treat people in the shortest time possible’.
This response to unprecedented demand was measured, calm and coordinated from clinicians and
managers at the Trust. Within just a few hours we had stepped down our alert and were back on track.
At no point did we turn away any blue-light ambulances or cancel any outpatient appointments.
47
The Trust has put in place a number of actions and a recovery plan to enable and sustain the flow of
patients through the department. Progress continues to be monitored through Inpatient capacity and
flow meetings and the Finance and Performance Committee (a subcommittee of the Board).
3.2 Other patient safety activity
Harm is suboptimal care which reaches the patient either because of something we shouldn’t have done
or something we didn’t do that we could have done. Hospital acquired infections, medication errors,
surgical infections, pressure sores and other complications are examples of harm which can occur within
a healthcare setting.
At Croydon Health Services NHS Trust we aim to reduce harm. We measure outcomes of much individual
harm to identify the impact of any improvement work we undertake. While we are proud of our
achievements which we have highlighted here, harm is taking place in the organisation and we still have
work to do to reduce clinical impact harm.
Infection prevention and control
The Trust continued with its extensive infection prevention and control work programme including
environmental inspections and hand hygiene audits.
During this reporting period the Trust reported one laboratory confirmed case of Methicillin Resistant
Staphylococcus Aureus (MRSA) bacteraemia (a type of bacteria that has become resistant to certain
antibiotics) against a target of zero. While this bacteraemia occurred in the community, Public Health
England has assigned the case to Croydon University Hospital as there were gaps in MRSA care pathway
prior to the patients discharge home.
The figure below shows the number of Hospital Acquired Infections (HAI) and Community Associated
Infections of MRSA bacteraemia per month for the previous 13 months. A map of our improvement work
focused on reducing the number of MRSA bacteraemia cases from 2008 to the current year is provided in
Appendix 8.
During this reporting period the Trust reported 15 laboratory confirmed cases of Clostridium difficile
within our inpatient services against a target of 17.
48
The figure below shows the number of Clostridium difficile positives for Croydon Health Services NHS
Trust and Community Samples (All age groups) March 2014 – March 2015.
Within the Croydon population there have been five deaths related to Clostridium difficile infection of
which two have been investigated under the serious incident process, of which one was an inpatient at
Croydon University Hospital. The criteria for investigating as a serious incident is where C. Difficile is
recorded on the medical cause of death certificate in one the following sections:
Ia - Disease or condition directly related to death
Ib - Disease or condition directly related to 1a
Ic - Disease or condition directly related to 1b
II - Other significant conditions contributing to death but not related to disease or condition.
Prevention and control of Clostridium difficile infection is a Croydon wide responsibility and requires
partnership working across a number of health and social care providers. All deaths associated with this
type of infection are reviewed, with lessons learnt being shared.
A map of our improvement work focused on reducing the number of MRSA bacteraemia cases from
2008 to the current year is provided in Appendix 9.
Viral Haemorrhagic Fever (VHF) preparedness
The Trust has been alert to the possibility of seeing suspected cases of VHF, including Ebola Virus.
Interventions to ensure that we remain prepared and vigilant have included:
•
•
•
•
Updating of Interim VHF guidance for staff each time new national guidance is published. This
guidance is accessible to all staff on the Intranet.
Guidance for managers of staff returning from affected areas (led by Occupational Health).
Face-mask Fit Test Training of staff in key areas.
The infection control team ran refresher training sessions for all VHF (Ebola) leads in February
2015. This included revision of all local action cards and reassessment of the leads competence in
the correct donning and doffing of personal protective equipment. Leads are then responsible for
reassessing staff in their areas.
49
Patient safety incidents
Following the publication of the Francis Report in February 2013, the Trust has been clear in its
expectation that staff report near miss and unexpected adverse events using the Trust’s web-based (Datix)
incident reporting system. Use of this reporting system enables the Trust to use its data well, regularly
interrogating the information recorded, carrying out investigations and trend analysis and interpreting
outcomes in relation to patient experience and safety.
The Trust’s Datix system is electronically linked to the National Reporting and Learning System (NRLS) and
patient safety incidents are uploaded to this central reporting and analysis centre. Local investigation of
all adverse events is supported within the Trust to ensure that appropriate challenge to existing practice is
encouraged and good practice identified is rewarded. Periods of reflective practice in supervision and
learning from investigations through regular learning events (known as clinical governance) are two ways
in which learning is shared throughout the organisation.
The Datix incident report form captures information to drive
the quality and usefulness of safety information captured
such as:
•
•
•
Being Open meetings with patients and their
representatives (Duty of Candour)
Flagging safeguarding concerns, including rationale
for why a safeguarding referral is not indicated
Recording root cause and lessons learnt.
During the period 4,131 adverse events and near misses
have been reported by Trust staff using the Trust’s reporting
system; of which 132 were reported and investigated as
serious incidents and 2 were classified as ‘Never Events’.
Following the publication
of the Francis Report in
February 2013, the Trust
has been clear in its
expectation that staff
report near miss and
unexpected adverse
events
Never Events are serious incidents that are wholly
preventable as guidance or safety recommendations that provide strong systemic protective barriers, are
available, at a national level and should have been implemented by all healthcare providers. Each Never
Event type has the potential to cause serious patient harm or death. However, serious harm or death is
not required to have happened as a result of a specific incident occurrence for that incident to be
categorised as a Never Event. Of the two Never Events in 2014-15 one related to a medication error and
the other to a wrong site surgery event.
Serious incidents are investigated using root cause analysis (RCA) investigation techniques. Investigation
panels are convened to bring together appropriate colleagues to complete the investigation including a
colleague who has been trained in RCA techniques. Serious incident final reports are also subject to an
internal quality assurance programme, with sign off by either the Medical Director or the Director of
Nursing, Midwifery and Allied Health Professionals prior to being sent on to the Clinical Commissioning
Group for external scrutiny of the report and appropriateness of the actions before final closure of the
serious incident.
Root causes and lessons learned are reported in a quarterly report to the Patient Safety and Mortality
Committee and the Quality and Clinical Governance Committee and is shared with our commissioners
and Clinical Quality Review meetings.
50
NHS England safety alert compliance 2014/15
Through the analysis of safety incidents, and safety information from other sources, NHS England
develops advice for the NHS that can help to ensure the safety of patients, visitors and staff. As advice
becomes available, NHS England issues alerts on potential and identified risks to safety.
At Croydon Health Services NHS Trust these alerts are coordinated and monitored by the risk
management team who work with clinicians and managers in the appropriate areas to confirm
compliance or to form an action plan to monitor compliance against them.
During the reporting period the Trust has received 145 alerts (a mix of estates, public health and medical
device notification) from the Central Alert System. 94% of alerts requiring acknowledgement were
responded to within the appropriate timeframe. Applicable alerts were disseminated to Trust staff who
acted on these alerts.
Estates (Estates Facilities Notices or Estates
and Facilities Alerts)
56
Drug Alerts - no response required
19
Medical Devices Alerts
53
NHS Patient Safety Alerts
17
Croydon Health Services NHS Trust is not compliant with all patient safety alerts for which compliance
deadlines have passed, with two alerts breaching. A list of the NHS Patient Safety alerts issued in 201415 is provided in appendix 10.
Harm free care
‘Harm free’ care is a national programme that helps NHS teams in their aim to eliminate harm in patients
from four common conditions:
•
•
•
•
Pressure ulcers
Falls
Urinary tract infections in patients with a catheter
New venous thromboembolism (VTE).
These conditions affect over 200,000 people each year in England alone, leading to avoidable suffering
and additional treatment for patients. In 2014-15 harm free care was a CQUIN and Croydon Health
Services NHS Trust performed well against national benchmarks [Higher percentage denotes high
performance] with the graph below showing the trend in harm free care both nationally and within
Croydon.
Data is taken directly from the Health and Social Care Information Centre website that calculate the harm
free percentages overall and for each subcategory monthly and can be viewed by everyone on
www.hscic.gov.uk/thermometer
51
More than 95% of our patients are receiving harm free care.
Working with our health and social care partners to drive up harm free
care
In August 2014 the Trust held an event through Listening Into Action. This ‘Big Conversation’ was led by
our Heads of Nursing (Patient Safety) aimed at identifying actions to reduce the number of people with
pressure ulcers. The group developed a multi-agency approach with the pressure ulcer taskforce being
expanded to include the Croydon Care Support Team.
Actions have included:
•
•
•
•
•
Integrated projects that engaged the entire health
Following a multieconomy including acute and community services,
agency ‘Listening Into
carers associations, council and private nursing home
Action’ event pressure
and, Croydon Council including safeguarding
ulcers acquired in
representatives
Enhanced communication across organisations,
nursing homes reduced
supported with newsletters and posters
by 55%
Sharing training programmes for formal and informal
carers
Utilised standard documentation for carers and
nursing home staff, such as care plans and use of the pressure ulcer pathway developed by
Croydon Health Services NHS Trust in hospital and community nursing service
Reaching out to the public with a Stop Pressure day
This has resulted in:
•
•
A 41% reduction in the number of pressure ulcers (all grades) since the project began. The most
significant reduction was to pressure ulcers acquired within nursing homes which showed a 55%
reduction
A 12% reduction in grade-3 pressure ulcers
As this first multi-disciplinary stakeholder conversation around pressure ulcer prevention and care was so
successful, another has been planned for May 2015 to sustain the improvements and to continue to work
collaboratively with our external partners.
52
Recognition and management of the deteriorating patient
We achieved a 31% reduction of in-hospital cardiac arrests in the past twelve months.
It is known that the majority of cardiac arrests that occur in hospital are preventable (NCEPOD 2012;
Resuscitation Council (UK) 2010). In 2014-15 the recognition and management of the deteriorating
patient was a CQUIN, with a target of reducing in-hospital cardiac arrests by 5%.
To achieve the reduction the Trust reviewed the approach to the recognition and management of the
deteriorating patient and made adjustments to both the educational and clinical aspects of this.
Acute illness management (AIM) course
We introduced the acute illness management (AIM) course in August 2014. The AIM course is nationally
recognised and has been designed to provide both theoretical and practical education to ward based
nurses/doctors and allied health professionals on how to recognise and respond to patient deterioration.
The course consists of workshops on the following elements:
•
•
•
•
•
•
Patient assessment
Hypovolemia
Sepsis and the “Sepsis Six” care bundle
Acute kidney injury avoidance and management
SBAR communication (Situational, Background, Action, Response)
Non-technical skills (human factors) associated with acute emergency events
Candidates also have the opportunity to participate in simulated scenarios. Candidates take a written
exam and complete a practical test. Since its introduction we have delivered AIM teaching to fifty four
nurses with a 95% pass rate.
Health care assistant acute illness management course
This course is aimed at health care assistants who would routinely look after patients who may
deteriorate. The course delivers education on the following aspects:
•
•
•
•
•
Systematic patient assessment
Theory and practice of taking and recording physiological observations e.g. heart rate,
temperature and blood pressure
Sepsis recognition
Recording and reporting signs of deterioration
SBAR communication (Situational, Background, Action, Response)
Following the course candidates complete a competency workbook. We have delivered this course to
eighteen of our healthcare assistants.
Mandatory and statutory training (MAST)
We have redesigned our MAST courses to have an increased focus on recognition of deterioration to
facilitate earlier appropriate referral and care.
53
Trigger tool
The trigger tool is a case-note review system of which we use the approved UK version of the IHI Global
Trigger Tool (GTT)™. Every in-hospital cardiac arrest is now reviewed looking for antecedents. We use the
Trigger Tool to facilitate this. We have found that there is a very strong correlation between ‘Harm
events’ (defined by the Trigger Tool) and cardiac arrests.
(G4=Unplanned re-admission within 30 days; G5=Cardiac arrest; G7=Complications of procedure or treatment;
L3=Abrupt drop on Hb; L4=Rising Creatinine more than twice baseline; L6=High or low K+; L7=Hypoglycaemia; L8=
Raised Troponin; and I1= Readmission to ICU/HDU)
We have been able to identify ‘Harm Events’ by ward area, which helps us to take action to try and
address these locally. We have also been able to track commonly seen ‘Harm Events’ and we are now in
the process of developing a risk tool that looks to facilitate the recognition of patients who may be at risk
of having a cardiac arrest. We believe this work would have significant patient safety benefits locally but
also would be of interest to other NHS Trusts nationally. Information on the GTT can be found at:
http://www.institute.nhs.uk/safer_care/safer_care/acute_adult_hospitals.html
Critical care outreach team
From 2013 the critical care outreach team has been able to deliver a twenty-four hour, seven days a week
clinical response to patient deterioration.
We are committed to ensuring that the achievements we have delivered are maintained and will continue
with:
54
•
•
•
Quarterly review of all in-hospital cardiac arrests using the GTT through a multi-professional
review committee.
Development of a ‘Cardiac Arrest Index Scoring System’ to facilitate earlier recognition of those
patients who have an increased chance of deterioration.
Continuation of the AIM and HCA educational courses.
Equipment
More than 500 beds and mattresses have been replaced. Benefits
include:
•
•
•
•
Prevention of pressure ulceration
Reduction in length of stay
Reducing financial cost
Efficient approach to equipment management
More than 500
beds and
mattresses have
been replaced
across the
hospital
3.3 Other effectiveness activity
‘Knowing How We’re Doing’ (KHWD) scorecard
The KHWD scorecard is a new, simple way for frontline teams to know if they are giving patients the very
best care. Its enables staff to access meaningful information online about their area performance. This
information is now being used at ward level to support improvement initiatives that all the
multidisciplinary teams can be involved in.
It looks at specific things that can have a real impact on patient care, so teams can track their team’s
progress. The scorecard shows what level of care individuals and teams are achieving using numerical
values, so you can see changes over time by whether numbers go up or down, and is structured using the
five CQC care domains to show if the care being delivered is patient-centred care.
The ward board was piloted on Purley 3 ward as part of quality improvements in 2013-14 and in 2014-15
these were successfully rolled out to every ward as part of the KHWD work stream. Ward teams share
their performance information with patients, visitors and staff to promote the culture of transparency
within the Trust. The boards are used as a focal point for weekly ward team meetings, where new ideas
are discussed and planned.
Reducing mortality
We use two measures of mortality both of which adjust our outcomes for the risk in our patient group.
These measures are HSMR (Hospitalised Standardised Mortality Ratio) and SHMI (Summary Hospital-level
Mortality Indicator). They compare the number of patients that would be expected to die, given the
severity of their conditions, when compared to national models against the number of patients who
actually die. Both are measures of mortality but have slightly different calculation methods.
Hospital Summary Mortality Ratio (HSMR)
We use two measures of mortality both of which adjust our outcomes for the risk in our patient group.
These measures are HSMR (Hospitalised Standardised Mortality Ratio) and SHMI (Summary Hospital-level
55
Mortality Indicator). They compare the number of patients that would be expected to die, given the
severity of their conditions, when compared to national models against the number of patients who
actually die. Both are measures of mortality but have slightly different calculation methods.
Hospital Standardised Mortality Ratio (HSMR)
•
The Hospital Standardised Mortality Ratio is the ratio of observed deaths to expected deaths for a
basket of 56 diagnosis groups which represent approximately 80% of in hospital deaths. It is a subset
of all and represents about 35% of admitted patient activity. Expected deaths are calculated for a
typical area with the same case-mix adjustment. The HSMR may be quoted as a percentage, when
HSMR is equal to 100, then this means the number of observed deaths equals that of expected. If
higher than 100, then there is a higher reported mortality ratio.
Figure 13 - The following graph shows the HSMR for the Trust over the last available 12 months (JanuaryDecember 2014) when All Diagnosis HSMR is 93.16 and is statistically lower than expected. Croydon is
one of 8 Trusts whose HSMR is as expected within the agreed Peer group, and for the last available
month (December 2014) it was 78.46.
Crude mortality
•
Crude Mortality – For the rolling 12 months (January 2014 – December 2014) the Trust’s crude
rate within the HSMR basket is 3.94% (and the Peer Group is 4.14%).
Figure 14: The HSMR Peer comparison is shown in the following funnel plot.
56
Summary Hospital Mortality Indicator (SHMI)
Summary Hospital Mortality Indicator (SHMI) - This gives an indication for each non-specialist
acute NHS trust in England where the observed number of deaths within 30 days of discharge from
hospital is 'higher than expected', 'lower than expected' or 'as expected' when compared to the national
baseline. A 'higher than expected' SHMI value should not immediately be interpreted as indicating good
or bad performance and instead should be viewed as a 'smoke alarm' which requires further investigation
by the trust.
The SHMI score indicates that the hospital mortality rate has reduced during July 13-June 14 period
compared to the previously available data from April 13-March 14. It is currently 100.87
SHMI Trend 10/11 to 12 months ending June 2014
•
The figure above demonstrates that Croydon Health Services NHS Trust has had a SHMI which has
consistently been reported ‘as expected’, or ‘lower than expected’.
The Trust is one of five Trusts within the chosen Peer group with an expected SHMI (using 95%
confidence intervals).
•
SHMI by Chosen Peers for all admissions
Optimising Care 24/7 for fractured neck of femur patients
For patients with a fragility hip fracture, care needs to be quickly and carefully organised to ensure the
most positive outcomes are achieved. Clinical characteristics of best practice are reported through the
national hip fracture database. Some of the issues identified were:
•
•
•
Too many delays in our internal care pathways
A lack of coordinated early senior review
A lack of early medical and anaesthetic review (patients should have a review the night before
surgery)
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Our actions
•
•
•
•
•
Reviewed and re-launched the internal fractured neck of femur care pathway eliminating delays
and issues identified by staff and patients.
Embedded the professional standards which aid compliance with the London Standards for neck
of femur care. These ensure that orthopaedic, medical and anaesthetic consultant job plans align
with requirements, and reorganised existing elderly care consultant posts to create a second
Ortho-geriatrician.
Improved teaching and training on trauma wards to improve trauma theatre efficiency.
Improved the electronic patient record templates, created a hip fracture bleep, developed an A to
Z of elderly trauma anaesthesia, put in place 7/7 therapy with physiotherapy bleep, and produced
an information leaflet for patients and their carers.
Outcomes for fractured neck of femur care improve if clinical investigations are not delayed after
a fall. The falls lead continued to do considerable work in this area. Falls training included in
mandatory and statutory training and in junior doctor teaching. All inpatient falls sustaining a hip
fracture are investigated as serious incidents and the findings presented at clinical governance
sessions (a forum where clinical teams share adverse events, lesson learned and best practice).
To support patients unable to go directly to the hip fracture unit due to lack of specialty beds, we put in
place formal liaison with the bed management team to ring-fence beds. To ensures that patients are
ready to go to theatre in the morning.
Further work
Further improvements to this pathway of care require significant transformation, with the need to
increase trauma theatre capacity (especially at weekends) and increase the number of pieces of specialist
equipment to support this efficiency.
Improved sustainability
The Trust is committed to tackling climate change by reducing its carbon footprint and embedding
sustainability in its operations. A key undertaking in early 2014 was to purchase two combined heat and
power plants (CHPs) in a move to significantly reduce onsite carbon emissions and utility costs.
The project was procured as an energy performance contract (EPC) which guarantees the hospital energy
savings each year. We generate our own electricity; we recover the waste heat and we save money
(estimated at £400k per year) which we can redirect into patient care.
3.4 Other patient experience activity
Outpatient transformation: a new way of working in main outpatients
A number of changes have been put in place in the past year that
have helped to improve patients’ experience of outpatient services
delivered in our main outpatient department at CUH.
Instead of the nursing/HCA team collecting each patient note from
the reception desk when a patient has arrived, the notes are now
placed in the consulting room or outside the room.
Advantages of this new system are:
•
•
Electronic whiteboards
containing information on
waiting times for clinics
are up in all main
outpatient areas to keep
patients informed.
It stops long queues at the front desk
Creates a calmer atmosphere for patients
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•
•
Clinicians have more time to review clinical notes before the patient is seen
Increases the time spent with the clinician
Medical records are delivered in 1-2 working days before the clinic, which has decreased the number of
missing notes.
Communication with patients in outpatients
To improve communication with patients, electronic whiteboards containing information on waiting
times for clinics are up in all main outpatient areas. In addition, to address complaints about
appointment letters, our correspondence has been reviewed with the inaccuracies corrected.
An outpatient’s information leaflet was designed and is now enclosed with every appointment letter
providing useful advice and information.
Text and voicemail reminder service
The Trust is making progress in reducing the ‘Did Not Attend’ rates (DNA) and has set an overall target of
10% as the baseline. As part of the LiA outpatients work stream a text messaging service was rolled out
in September 2014 to 20 specialities. The graph below shows the overall effect on the trust performance
of DNAs.
Key performance indicators
The department developed a set of key performance indicators for outpatients that are now accessible by
all managers. This enables the identification of trends in performance and corrective action to be taken.
Further improvement work
Further improvements are planned to build on work already undertaken. These include:
•
•
•
•
Changes to department signage from the car parks
Review of our IT systems to respond to requests from patients for more information to be sent to
them via email
Work through the potential to have automated check–in kiosks for the larger outpatient
departments
There is still evidence of patients not receiving their letters in a timely way. This is often due to
short notice cancellations and clinic template changes. Work is on-going with the specialities to
minimise last minute template changes and clinic cancellations.
As a result of outpatient improvement work, the Trust has seen an increase in the number of patients
recommending our outpatient services (see table below), achieving 82% in December 2014.
Month
Target
Main outpatients
department total
October
90%
70%
November
90%
75%
December
90%
82%
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In 2012 it was identified that the Trust was experiencing a serious lack of space in the health records
library. The Trust took action and arranged for approximately 360,000 records to be stored by an offsite
facility. This year the medical records manager has been working with the supplier to reduce the
numbers of missing notes within the clinics.
56 The graph below shows the missing notes from November 2014 to January 2015. Despite a blip in
January caused by the supplier missing a notes order and delivering the consignment late after pinks
(temporary notes) had been issued to departments, in most cases the full notes were available. This
improvement has a positive impact on patient care and experience when they are seen by a clinician in
clinic or on the ward.
42 Totals
21 21 24 30
27 40
Totals
33 50
42 60
8 10
6 20
0
Week4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10 Week 11 Week 12 Week 13
When patients are seen in clinic without their medical notes being available this can impact on the
confidence they have in the care being delivered and therefore impact negatively on their patient
experience, or even necessitate their appointment being postponed.
On talking with our outpatient staff they report that clinical notes are now delivered a minimum of 2 days
in advance of appointments and from January 2015 this has increased to seven days ahead giving more
time to look for ‘missing notes’.
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Community nursing: better together
Our community nursing team introduced a ‘Pass it on’ card, so that hospital staff are aware that patients
are under the care of community services staff along with an improved referral form for community
nursing. This incorporated a discharge checklist to inform our community staff when patients are
admitted to hospital and when they are discharged back home. This checklist helps to ensure that
patients are discharged with the right information and equipment. A different referral system for
different services was replaced with one point of referral – Single Point of Assessment which was one of
the Trust priorities in 2014-15. (See pg.34)
‘Patient Led Assessment in the Care Environment’ audit (PLACE)
Every NHS patient should be cared for with compassion and dignity in a clean, safe environment. PLACE
assessments provide a framework to review how the environment supports patient privacy and dignity,
quality of food provided, cleanliness and general building maintenance. The inspectors are a mix of Trust
members, external inspectors and patient representatives. The group is at liberty to visit any ward or
department in which patient care is provided.
The assessments take place every year, and results are reported publicly. The most recent PLACE
assessment took place on the 14 April 2014, with no major concerns raised. The next assessment planned
for April 2015. The figure below demonstrates the output of the PLACE assessment in April 2014.
2015 Health and Social Care Information Centre
Dementia not measured in last PLACE assessment - this is a new requirement in 2015/16.
End of life care
In line with the recommendations made by the independent
review of the Liverpool Care Pathway (LCP), Croydon Health
Services NHS Trust withdrew the LCP from clinical use in July
2014. The Board appointed Godfrey Allen, a non-executive
director to be an active member of the Croydon Health Services
NHS Trust End of Life Care Steering Group, providing
independent assurance and to champion end of life care at
board level.
The Croydon Macmillan Palliative care team provide a 9 to 5
face to face service for CUH patients across Monday to
Saturdays. Out of hours telephone advice to CHS professionals
is provided by the Consultants on call for St Christopher’s
hospice.
In June 2014, a
Listening into Action
event with patients
helped us to develop an
electronic nursing care
plan for end of life care
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In June 2014, the team held a Listening into Action event to identify from general staff and service users
what their priorities were in the caring for dying patients. Feedback from this event and the launch of
the National five priorities of care document helped us to develop an electronic nursing care plan on our
electronic patient record (CRS Millennium), called the ‘care of the dying patient plan’. We have also
designed and piloted two templates for the medical teams to use when they document an initial and
follow up assessment of a dying patient.
The Trust plans to launch the five priorities of care for the dying patient in April 2015. These five
priorities of care formulate the Trust’s End of Life Care Strategy.
In response to results obtained from our National Care for the Dying Acute Hospitals Audit (2013), we
have developed and implemented an ‘order set’ of medications for the five key symptoms that occur at
the end of life, which are prescribed electronically. This has improved the prescribing of these medications
at the end of life.
Cancer Patient Forum
Two events have taken place, led by our Nurse Consultant (Cancer), to listen and obtain views on how
we can improve the cancer patient experience. These were held in April 2014 and December 2014 with
over 60 participants. The first event asked two questions:
•
•
Which aspects of care or treatment helped most during your cancer journey or the journey of
someone you cared about?
Which aspects of care or treatment helped least during your cancer journey or the journey of
someone you cared about?
As a result we have:
•
•
•
Introduced business cards for all clinical nurse specialist so patients and carers have contact
numbers easily accessible
The patients with a cancer diagnosis are made aware to the Acute Oncology Service who can
then ensure patients have access to appropriate cancer professionals.
Discussion with other health care providers involved in cancer care has been held to see how we
can improve communications. At Croydon the cancer clinical nurse specialists have access to
Royal Marsden Hospital data so they can have clearer ideas of the discussion held there.
Patient stories
Patient stories are a range of stories told by individuals from their own perspectives. The idea is to gain an
understanding of the healthcare experience of the storyteller; what was good, what was bad and what
would make the experience more positive. An individual story is not in itself representative of all patient
experiences, but each story is valid, as it is the individual’s healthcare experience. Collectively, stories can
help us build a picture of what it is like as a service-user and how we can improve the service we provide.
In 2014-15 the Board heard a patient story at each of its public meetings.
Friends and Family Test (FFT)
The thoughts, opinions and observations of our patients and community about all aspects of our services
both in the community and hospital setting are very important to us. Our aim is that every patient’s
experience is an excellent one and understanding what matters most for our patients and their families is
a key factor in achieving this.
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The Friends and Family Test (FFT) is an important feedback tool that supports the fundamental principle
that people who use NHS services should have the opportunity to provide feedback on their experience. It
asks people if they would recommend the services they have used and offers a range of responses. When
combined with supplementary follow-up questions, the FFT provides a mechanism to highlight both good
and poor patient experience. In 2014-15 FFT was a national CQUIN.
Friends and Family Test (FFT) score
The FFT score is reported up to the period of January 2015 and the percentage of respondents who
would/would not recommend a service to their friends and family.
FFT results Accident and Emergency South West London Sector
Our aim is that every
patient’s experience is
an excellent one and
understanding what
matters most for our
patients and their
families is a key factor
in achieving this.
FFT results Inpatients South West London Sector
FFT results Maternity South West London Sector
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National FFT CQUIN results
The FFT CQUIN framework prioritises indicator of increased response rates, as well as to ensure the
implementation of the national FFT to service areas according to the national implementation
programme. The aational requirement for the FFT in 2014 - 2015 is to implement the system in adult
outpatients and adult day cases to national standards by October 2014, which was achieved.
Additionally, the national system had to be implemented in adult community services by 1 January 2015,
and this is also achieved. The FFT implementation to national standards in children and young people’s
services is on track for implementation by April 2015.
Responding to FFT comments
The feedback from patients and in particular their comments is a rich source of information for individual
services. Patients are asked:
•
•
What is the reason for your score?
How can we improve?
By reviewing comments written by patients, it is possible to identify how patients have had a positive
experience and their recommended ways to improve. Our actions to improve patient and service user
experience have already been described in the section in this report on our quality priorities 2014-15.
Patient Advice and Liaison Service (PALS) and Complaints
In creating a complaints process which values patients, relatives, carers and staff, the PALS and
complaints department has restructured the way they process complaints, with every complainant now
being assigned a named coordinator to be the first point of contact for information. And the coordinators
now proactively are phoning each new complainant. This has resulted in more complaints being resolved
informally and quickly which is a fantastic result for service users.
To support this improvement work the group has:
•
•
Worked with a patient volunteer, to create a film to raise awareness of the importance of
handling complaints well from the start using empathy and understanding, viewing them
positively and listening to people’s concerns. The film has is a valued resource which can be used
for training.
New patient friendly email boxes have been created on the Trust website for PALS, Complaints
and Compliments.
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•
A Complaints Handling Assessment Form is attached to every complaint on the Trust reporting
system for guidance on how to investigate a complaint
•
A new practical approach to Complaints Training which includes group work around best
practice response writing.
3.5 Workforce factors
The Trust cannot achieve its objectives without its dedicated workforce. The Trust and its staff have
remained committed to working with its commissioners to provide high quality patient centred services,
and the Trust Development Authority’s (TDA) continued support to Croydon Health Services NHS Trust.
One of our key priorities remains working with staff across our organisation, to ensure we recognise their
strengths and learn and build on best practice to develop a cohesive workforce with a shared vision and
values, aligned to our business objectives. The work this year has focused staff feeling informed, valued
and listened to wherever and whatever they do, and improving communication across the whole
organisation.
How we keep everyone informed
As part of our commitment to deliver long-term improvements to staff engagement the communications
team have:
• Built a new intranet, called ‘CHS-Connect’. It is to use and has a better search and archive
function, up-to-date staff contact information linked to the electronic staff record (ESR). This
went live in February 2015
• Trust Focus – monthly staff cascade with participation and discussion, films and presentations
from staff as well as members of the senior team
• Staff Open Surgeries held at a number of Trust bases, with a wider range of times to reach more
staff
• Re-launched our staff newsletter ‘What’s New’ to be more engaging, timely and informative
• Use of social media to increase engagement
Annual staff survey (2014)
The 2014 annual staff survey was conducted between October and December 2014. The figure below
shows how Croydon Health Services NHS Trust compares with other acute Trusts on an overall indicator
of staff engagement. Possible scores range from 1 to 5, with 1 indicating that staff are poorly engaged
(with their work, their team and their trust) and 5 indicating that staff are highly engaged.
The trust's score of 3.71 was average when compared with trusts of a similar type.
The 2014 staff survey results remain encouraging as for a second year Croydon Health Services NHS Trust
compares with other acute trusts in England. Through our continued engagement work using Listening
65
into Action (LiA) the Trust has been harnessing the skills and knowledge of our staff to improve services,
processes and the work environment.
Our staff feel amongst the most enfranchised in the NHS, with 75% feeling that they are able to
contribute to improvements at work according to the results of the national NHS staff survey published
on 24 February 2015. Our efforts over the past two years to create an environment where staff feel
engaged and empowered to deliver improvements to our patients continues to deliver better outcomes
for all.
The LiA approach is also translating into Trust staff feeling that they are working better together as a
team (and within teams), with their scoring for effective team working increasing from last year to 3.81
out of 5 and beating the national average of 3.74.
Staff pledges
We have created and introduced four simple
and easy to remember staff pledges,
incorporating “Hello my name is”. These are
being embedded into job descriptions,
induction, Trust customer service training and
promoted around the Trust.
The Staff Attitudes, Behaviour and
Communication (ABC) policy has been
promoted around the Trust on colourful posters
in public areas so it’s not just a document sitting
on the intranet. We are currently working on
putting the pledges into our staff appraisal (PDR)
paperwork so that the appraiser can rate
whether an individual upholds them.
The 2014 annual staff survey results have been aligned to demonstrate how embedded our pledges are
across the Trust. Positive findings are indicated with a green arrow (e.g. where the trust is in the best
20% of trusts, or where the score has improved since 2013). Negative findings are highlighted with a
red arrow (e.g. where the trust’s score is in the worst 20% of trusts, or where the score is not as good
as 2013). An equals sign indicates that there has been no change.
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STAFF PLEDGE 1:
To provide all staff with clear roles,
responsibilities and rewarding jobs.
PLEDGE 2:
To provide all staff with personal
development, access to appropriate
education and training for their
jobs, and line management support
to enable them to fulfill their
potential.
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Occupational health and safety
Errors and incidents
STAFF PLEDGE 3:
To provide support and
opportunities for staff to maintain
their health, well-being and safety.
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Violence and harassment
STAFF PLEDGE 3:
To provide support and opportunities for staff to maintain their health,
well-being and safety
STAFF PLEDGE 3:
To provide support and
opportunities for staff to maintain
their health, well-being and safety
STAFF PLEDGE 3:
To provide support and
opportunities for staff to maintain
their health, well-being and safety
Health and well-being
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STAFF PLEDGE 4:
To engage staff in decisions that
affect them, the services they
provide and empower them to put
forward ways to deliver better and
safer services.
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Highlights and lowlights of the key findings
Improvements in staff feeling that their role makes a difference to patients and staff feeling that there is
effective team working in place is encouraging. Work pressure felt by staff and the percentage of staff
working extra hours is a reflection of the current level of vacancies across the Trust especially in nursing
and concentrated work on recruitment and retention is in progress.
The percentage of staff feeling that they received job-relevant training, learning or development in the
past 12 months is an area of local management development but also a potential reflection of the current
staff shortages across the Trust. Releasing staff to attend training and development sessions is difficult
and must not put patient safety at risk.
The percentage of staff witnessing potentially harmful errors, near misses or incidents in the past 12
months has decreased but staff do not think that there is fairness and effectiveness in incident reporting
procedures. The percentage of staff agreeing that they would feel secure raising concerns about unsafe
clinical practice has also reduced. Following the recent launch of Sir Robert Francis QC’s Freedom to
Speak up Review, the Trust is currently assembling a working group to review the Trust Whistleblowing
Policy and to further develop a culture for raising concerns in the workplace.
The percentage of staff experiencing harassment, bullying or abuse from other staff in the past 12
months has slightly improved but the Trust is still well below the national average. The Trust’s
Respect@work programme and team of advisors will be refreshed in 2015.
Staff report that communication between senior management and staff could be improved as our
performance against this indicator has fallen since the 2013 survey. A
combination of management development around effective team
Staff motivation has
development and management and further uptake of LiA methodology
should assist in improving this shortfall. Managers engaging and valuing
improved and sits
staff would assist with staff job satisfaction which has reduced slightly
slightly above the
since 2013.
national average
Staff recommending that Trust as a place to work or receive treatment
has increased slightly but not demonstrably considering the huge
amount of work with LiA to engage staff in making effective change
happen. Despite the slight increase CHS sits well behind the national
average. Conversely staff motivation at work has improved and sits slightly above national average.
Safe staffing
From May 2014, all hospitals in England are required to publish information about the number of nursing
and midwifery staff working on each ward, together with the percentage of shifts meeting safe staffing
guidelines.
This means that if you are a member of staff, patient or relative, you will be able to examine the staffing
history of a ward. It is the same data that is seen by hospital Boards, commissioners and regulators. This
initiative is part of the NHS response to the Francis Report which called for greater openness and
transparency in the health service.
Croydon Health Services NHS Trust has a very clear system in place, with nursing and midwifery clinical
leaders across the trust visiting clinical areas at least daily to ensure safe staffing. There is also a process
for quickly escalating any areas of concerns to the director of nursing. The acuity/dependency of patients
(how sick or dependent they are) ultimately affects the type and amount of care patients need. We
therefore ‘flex’ the number of care staff needed, depending on our patients’ needs, to make sure we
have the right staff, with the right skills, in the right place. Information about staffing levels is published
monthly.
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Croydon Health Services NHS Trust has taken the following actions to the risks and mitigation being
taken to support the delivery of high quality care. It includes an exception report where the actual nurse
staffing levels have either fallen below a 90%, or have exceeded a 110%, threshold.
A report to the Nursing, Midwifery and Allied Health Professionals Board forms part of the organisation’s
commitment to providing open and transparent information, through the publication of this data on the
Trust’s Website. It includes an overview of the monthly UNIFY data submission that is published on the
NHS Choices website and further local analysis by clinical speciality.
The Trust is required to report on the ‘actual against planned/ staffing levels for each month. The wards
where staffing pressures have been identified are highlighted, and the potential impacts on patient care
are assessed using the Nursing Quality indicators. Staff are encouraged to report staffing issues on Datix
as a safety incident.
Visible leadership
Our patients and staff have said that the Trust’s leaders were not often seen, and that they could be
more helpful, supportive and welcoming to our patients, visitors and colleagues. We have launched an
innovative Trust-wide movement to provoke a step-change in the way we communicate and care called
‘Visible Wednesdays’. Every Wednesday, from 9 am to 12 noon:
•
•
•
Our hospital matrons will have protected ward time to care for patients and to support their
teams
We are encouraging all team leaders to clear their diaries of
We have launched an
all but essential meetings to work side-by-side with
innovative Trust-wide
colleagues to improve patient care and experience
movement to provoke
We are encouraging all staff to speak and not send – to stop
a step-change in the
relying on email and speak to people face-to-face or by
way we communicate
telephone
For 2015 we have moved our monthly Trust Focus briefing for staff
to Wednesdays, to meet Chief Executive John Goulston and the executive team face-to-face with and ask
questions of senior managers.
Other activities of visible leadership
•
•
Displaying who is on the Board around the organisation on posters so that they are easily
recognisable to staff and patients
Displaying in the venue where we hold induction a ‘wordle’ from our LiA Visible leadership
conversation and oversized art work of inspirational leaders so that we talk about visible
leadership from the moment staff join the Trust
72
•
•
•
Senior nurse manager / visible leaders now where bright red uniforms so they are easily
recognised by staff, patients and visitors.
Executive walk-rounds provide visible leadership out of hours at nights and weekends
Visible leadership encouraged and promoted through job swaps – staff spending a half day in a
part of the hospital completely unknown to them and doing that person’s job. “A Day in the life
of”.
What next - ‘Back to the floor’?
In 2015 all directors will complete two ‘Back to the floor’ placements this year during Visible Wednesday,
(The first placement to be completed by June 2015 and the second by December 2015). Placements will
be logged and feedback collected from both the executive director and the host member of staff on their
experience and learning, which will be shown to the Trust Board as evidence that the executive team are
getting out and about within the Trust. The aim is that senior staff/directors will be exposed to the
working life of colleagues at all levels.
The Friends and Family Test for staff
Lessons learnt from the Francis report highlighted that staff wellbeing can act as an early warning sign for
the quality and safety of patient care, and individual stories and complaints can be red flags. Recent
research has also shown that the extent to which staff would recommend their trust as a place to work or
receive treatment shows a high correlation with patient satisfaction. Therefore listening better to the
experiences of staff, as well as patients and their relatives, is imperative for improving the patient
experience. In 2014-15 the Trust implemented the Friends and Family Test for staff.
What is the NHS Staff Friends and Family Test (Staff FFT)?
The Staff FFT consists of two questions through which organisations can take a pulse check of how staff
are feeling, by asking:
•
•
How likely are you to recommend Croydon Health Services NHS Trust to friends and family if they
needed care or treatment?
How likely are you to recommend Croydon Health Services NHS Trust to friends and family as a
place to work?
Participants respond to FFT using a response scale, ranging from ‘extremely unlikely’ to ‘extremely likely’.
In addition, the Staff FFT asks staff to provide comments on why they chose their answer to help us
identify what we are getting right and where we can improve.
The closer the score is to +100, the more staff that have said they are ‘extremely likely’ to recommend
our Trust to their friends and family as a place to receive care and treatment or as a place to work. The
closer the score is to -100, the more staff have said they would ‘not recommend’ our Trust.
•
In Quarter 2 the proportion of staff who would recommend the Trust to their friends or family if
they needed care of treatment was 51%.
•
In Quarter 2 of the Staff FFT the proportion of staff who would recommend the Trust to their
friends or family as a place to work is 53%.
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Staff awards
Our annual staff awards celebrate the outstanding achievements of our staff, day in day out, which make
a real difference to people’s lives. We celebrated our outstanding staff at our annual Croydon Stars
award ceremony on Thursday 30 April 2015, at the event we will be giving awards for:
•
•
•
•
•
•
Long service
Incredible customer service
Listening into Action team of the year
Tremendous teamwork
Landmark Leadership
The Ken Coates volunteer of the year award
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3.6 Other developments
New A&E bid – work to develop the business case and plans
When the CQC inspected the Trust in 2013, they found the emergency department to be
well-led and providing a good standard of care, but they agreed that care could be
improved with a new facility and more open design. Our new department has been
designed by Croydon’s own emergency care doctors and nurses. The new emergency
department at CUH will:
• Be a third of the size bigger
• Give clinicians ‘direct line
of sight’ of their patients
• Give the Trust flexibility to meet changes in demand
Partnership working
CHS is an active member of the Health Improvement Network. The Health Innovation Network (HIN) is
the academic health science network for South London. Established in May 2013, the HIN is a
membership organisation that seeks to drive lasting improvements in patient and population health
outcomes by spreading the adoption of innovation into practice across the health system, capitalising on
the teaching and research strengths of members.
The HIN’s diverse membership includes all healthcare providers (community, acute, mental health and
primary care), commissioners, local authorities and higher education providers. The HIN’s work
programmes are underpinned by strong relationships and collaboration with both patient and industry
partners. Bringing together training and education, clinical research, informatics and innovation, the HIN
works to improve patient outcomes and experience. As part of the HIN the South London Patient Safety
Collaborative was formed and Croydon Health Services NHS Trust has played an active role a part of the
design team for the Promising Practice event that was held in April 2015 presenting the work that they
achieved on the deteriorating patient outcomes.
Croydon Best Start
We are working with our local authority to become the first UK borough to fully combine services for
children and young people. We have received £1.5m funding from the Department of Communities and
Local Government to improve the health and wellbeing of children under five in Croydon and we will do
this by bringing together health visiting, children’s centres, early years, midwifery and the voluntary
sector.
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Part 4
Appendix 1
Croydon Clinical Commissioning Group Statement to the
Directors of Croydon Health Services NHS Trust on the Annual
Quality Account
Croydon CCG welcomes the opportunity to comment on Croydon Health Services NHS Trust Quality
Account 2014/15. We congratulate the Trust on its achievements and in particular, commend the
progress made in relation to the reduction in the number of acquired Pressure Ulcers as well as remaining
below the national average for Harm Free Care.
The 2015/16 priorities are consistent with those identified by the CCG. The CCG looks forward to
working with the Trust to quantify expected improvements in terms of measurable outcomes and on the
greater use of meaningful data to demonstrate improvements which have been achieved. This will
provide evidence to support the effectiveness of new systems and pathways to achieve this. The CCG
very much welcomes the achievements of the rapid response service. It would be valuable to see more
information and outcomes achieved to communicate the performance of community services.
The Trust has worked hard to improve its safety culture through the Sign up to Safety Programme,
although we note continues to have a lower reporting rate through the National Reporting and Learning
System than some of its peers. The CCG has been focused on being assured in relation to the
comprehensive and timely reporting of Serious Incidents, and to be assured that the Trust has in place a
planned improvement plan for training, identification and reporting these incidents, and also for
cascading the learning to all relevant staff.
The positive Harm Free Care performance is commended; it should be noted that this is a 1 day monthly
snapshot, rather than a yearly figure.
The CCG welcomes the emphasis on prioritising improvements in the patient experience. At the time of
writing the latest national inpatient survey results have not been published, but the CCG would wish the
Trust to consider a more ambitious target for 2015/16 building on the previous plan to improve by 10%,
taking account of the previous survey results.
A large number of national and local audits have been carried out throughout the year, with identified
areas to improve quality. Although helpful it would also be informative if the Trust identified the extent to
which these audits demonstrated the extent to which it had met or failed the requirements of the audits,
or how these are going to be implemented, evidenced or sustained, and with more reflection on what
the results will mean.
The work the Trust has taken forward to improve cancer waits e.g urology/prostate cancer is noteworthy,
and of course can be built on further.
A priority for local GPs is improving discharge summaries, and the CCG welcomes the ‘pledge’ to improve
communications with GPs as patients move between different settings, and looks forward to the detailed
implementation.
The CCG remains committed to working collaboratively to assist the Trust on delivering its actions,
achieving improvement, and sustaining it through effective contract management and collaborative
working, and looks forward to a positive outcome for 2015/16.
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Appendix 2
Healthwatch Croydon Statement to the Directors of Croydon
Health Services NHS Trust on the Annual Quality Account
This Quality Account was considered by Healthwatch Croydon, a reflection of the patient feedback on
the range and the quality of healthcare services provided by the Croydon Health Services NHS Trust.
As stated in the Health and Social Care 2012 legislation, the role of Healthwatch is to be the independent
consumer champion for health and social care. One core function for a Healthwatch is to gather patient
experience and inform decision-makers health and care services at a local and national level.
In 14/15 Healthwatch Croydon had a particular focus on wards at Croydon University Hospital. Between
29th March 2014 and November 2014 there were two Enter and View visits. In March Healthwatch
Croydon volunteers visited the Urgent Virgin Care Centre, the Enter and View report recommended the
service ‘ensure patients understand treatment’ and ‘ensuring waiting times for urgent care do not exceed
twenty minutes.’ In November, Wandle Ward 2 and 3 had an Enter and View visit; one recommendation
suggested ‘an internal review of discharge procedures/ management to ensure patients and their relatives
have sufficient notice and information regarding patient discharge arrangements.’
Hospital discharge focus group
Healthwatch Croydon hosted a focus group for Croydon residents on hospital discharge, subsequently
commissioning a project on the patient experience during the discharge process. The key points from the
focus group in January 2015 were ‘clear communication on the patient journey with information with a
clear plan’ and ‘ensure the care plan is in place before the patient is discharged; the care team should
work together and the family/carers should be engaged in the care package.’
Healthwatch Croydon outreach
Healthwatch held outreach stalls at Croydon Hospital and asked patients their recent experience in health
and social care. Generally people said they had a positive experience at the hospital although one
identified that initially they were told they would go home but instead were admitted to a nursing home.
‘the patient’s husband felt the standard of care given to his wife during Intensive Care was extremely
positive, the family was advised that his wife would receive rehab treatment instead she was transferred
to an elderly nursing home, where no rehab was provided.’
Croydon Health Services NHS Trust Quality Account report
PLACE assessments will continue to be supported by Healthwatch Croydon. Patient stories are explained
yet examples are not given and how they have had an impact on improving the quality and design of a
service. Healthwatch Croydon welcome complaints being resolved more quickly by PALS but the report
does not identify the particular consistent issues raised by patients and whether these were escalated to
the appropriate department to re-evaluate their service. Healthwatch Croydon are developing links with
patient liaison, quality and delivery staff and will continue to support and advice on patient engagement.
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Appendix 3
Croydon Overview and Scrutiny Committee Statement to the
Directors of Croydon Health Services NHS Trust on the Annual
Quality Account
Members of the Health, Social Care and Housing Scrutiny Sub Committee welcomed the opportunity to
comment on the draft Quality Account. Whilst the Committee acknowledged and welcomed the actions
and initiatives being explored to improve the quality and standards of care currently provided, it
recognised that there is a journey ahead for the Trust to improve and maintain satisfactory standards of
care at the point of delivery as the effectiveness of the initiatives was not demonstrated across all
disciplines Trust wide.
The Trust agreed that it was important to utilise best practice and as mentioned the immediate priorities
are best practice focused, looking at what works well nationally and sector wide, coupled with the joint
working with the Care Quality Commission and key stakeholders to develop a quality improvement
programme, this should deliver positive outcomes.
The Committee repeatedly asked of each pathway “what does success look like” and were pleased to
learn that there had been some movement in the delivery of the quality improvement plan. The
Committee repeatedly challenged the Trust to confirm how it would improve perceptions and reputation
of the Trust. It was noted that the CQC inpatient service results were unavailable at the time of reporting
therefore no recent comparisons could be made.
That the Listening Into Action (LIA) programme had been rolled out to include patients was viewed as a
positive step to gaining qualitative data. This, together with compassion and enhanced communication
was seen by the committee as one of the underlying drivers to change the perceptions of services users
and gaining the support and the trust of healthcare professionals. Committee noted the effectiveness of
LIA by the introduction of the “home by lunch” initiative that aimed to discharge patients by lunchtime
to avoid vulnerable patient being discharged late into the night with little or no support in place.
Committee noted the breadth of the Trust’s healthcare provision, and also noted that Community Health
Services were barely touched upon during committee meetings. As a consequence, and in order to
enhance Committee Members’ knowledge of the services provided in the community, the Trust hosted
several visits to various settings. Committee members were given the opportunity to see and discuss with
staff how strategies and policies developed at senior management and board level had impacted in the
clinical area and could see first-hand examples of best practice: they were also able to meet with and
discuss with staff groups what some of the constraints are and where funding gaps shaped service
delivery.
Overall the committee felt that the Trust leadership team appeared positive in its approach to improving
the level of staff engagement. It was evident to committee that as the Listening Into Action programme
continued to produce changes in service delivery; It was giving staff a strong sense of ownership and
belonging.
The Trust had made some progress to maximise instance of service users engagement, using open days
and inpatient sessions. Data analysis of the Friends and Family cards appeared to demonstrate some
improvement on the patient side, however there had been no significant improvement staff side.
Committee challenged why they should believe the Trust assurances this time any more than the
assurances they had received before. On hearing the response Committee was left with the impression
that this Trust Leadership Team’s actions to date showed they were better placed to make improvements
in services and on changing perception and improving the Trust’s reputation. The programme aimed to
improve the patient experience trust-wide and in particular within the accident and emergency
department. The concerns previously raised about the services provided by Virgin Care and how it
appeared disjointed and disconnected remains a concern and, it appears, remains high on the Trust’s
agenda. Committee noted that Virgin Care is commissioned separately by the Croydon Clinical
Commission Group (CCG) and does not form part of the performance management of the Trust.
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Appendix 4
Independent Auditors’ Limited Assurance Report
to the Directors of Croydon Health Services NHS
Trust on the Annual Quality Account
We are required to perform an independent assurance engagement in respect of Croydon Health Services
NHS Trust’s Quality Account for the year ended 31 March 2015 (“the Quality Account”) and certain
performance indicators contained therein as part of our work. NHS trusts are required by section 8 of the
Health Act 2009 to publish a quality account which must include prescribed information set out in The
National Health Service (Quality Account) Regulations 2010, the National Health Service (Quality Account)
Amendment Regulations 2011 and the National Health Service (Quality Account) Amendment
Regulations 2012 (“the Regulations”).
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance consist of the following
indicators:
•
the rate of clostridium difficile infections
•
the percentage of patients risk-assessed for venous thromboembolism (VTE)
We refer to these two indicators collectively as “the indicators”.
Respective responsibilities of directors and auditors
The directors are required under the Health Act 2009 to prepare a Quality Account for each financial
year. The Department of Health has issued guidance on the form and content of annual Quality Accounts
(which incorporates the legal requirements in the Health Act 2009 and the Regulations).
In preparing the Quality Account, the directors are required to take steps to satisfy themselves that:
•
the Quality Account presents a balanced picture of the Trust’s performance over the period
covered;
•
the performance information reported in the Quality Account is reliable and accurate;
•
there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to review to confirm
that they are working effectively in practice;
•
the data underpinning the measures of performance reported in the Quality Account is robust
and reliable, conforms to specified data quality standards and prescribed definitions, and is
subject to appropriate scrutiny and review; and
•
the Quality Account has been prepared in accordance with Department of Health guidance.
The Directors are required to confirm compliance with these requirements in a statement of directors’
responsibilities within the Quality Account.
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
Regulations;
•
the Quality Account is not consistent in all material respects with the sources specified in the NHS
Quality Accounts Auditor Guidance 2014-15 issued by DH in March 2015 (“the Guidance”); 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
Regulations and the six dimensions of data quality set out in the Guidance.
We read the Quality Account and conclude whether it is consistent with the requirements of the
Regulations and to consider the implications for our report if we become aware of any material
omissions.
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We read the other information contained in the Quality Account and consider whether it is materially
inconsistent with:
•
Board minutes for the period April 2014 to June 2015;
•
papers relating to quality reported to the Board over the period April 2014 to June 2015;
•
feedback from Commissioners (Croydon CCG) dated June 2015;
•
feedback from Local Healthwatch (Croydon) dated June 2015;
•
the Trust’s complaints report published under regulation 18 of the Local Authority, Social
Services and NHS Complaints (England) Regulations 2009, dated 2014–15;
•
feedback from other named stakeholders involved in the sign off of the Quality Account
(Croydon Overview and Scrutiny Committee);
•
the latest national patient survey dated May 2015;
•
the latest national staff survey dated 2014;
•
the Head of Internal Audit’s annual opinion over the Trust’s control environment dated May
2015;
•
the annual governance statement dated 3 June 2015; and
•
the Care Quality Commission’s Intelligent Monitoring Report dated May 2015;
We consider the implications for our report if we become aware of any apparent misstatements or
material inconsistencies with these documents (collectively the “documents”). Our responsibilities do not
extend to any other information.
This report, including the conclusion, is made solely to the Board of Directors of Croydon Health Services
NHS Trust.
We permit the disclosure of this report to enable the Board of Directors to demonstrate that they have
discharged their governance responsibilities by commissioning an independent assurance report in
connection with the indicators. To the fullest extent permissible by law, we do not accept or assume
responsibility to anyone other than the Board of Directors as a body and Croydon Health Services NHS
Trust for our work or this report save where terms are expressly agreed and with our prior consent in
writing.
Assurance work performed
We conducted this limited assurance engagement under the terms of the guidance. 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;
•
testing key management controls;
•
analytical procedures;
•
limited testing, on a selective basis, of the data used to calculate the indicator back to supporting
documentation;
•
comparing the content of the Quality Account to the requirements of the Regulations; and
•
reading the documents.
A limited assurance engagement is narrower 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
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 impact 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 thereof, may change over time. It is important to read the Quality Account in
the context of the criteria set out in the Regulations.
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The nature, form and content required of Quality Accounts are determined by the Department of Health.
This may result in the omission of information relevant to other users, for example for the purpose of
comparing the results of different NHS organisations.
In addition, the scope of our assurance work has not included governance over quality or non-mandated
indicators which have been determined locally by Croydon Health Services NHS Trust.
Basis for qualified conclusion
For the indicator reporting the percentage of patients risk-assessed for VTE we have been unable to
obtain an audit trail for the maternity cases included in this indicator because the Trust's Information
Department only receives data on the total number of VTE assessments from maternity. We were
therefore unable to gain sufficient assurance to conclude that the indicator is reasonably stated in all
material respects in accordance with the Regulations and the six dimensions of data quality set out in the
Guidance.
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
Regulations;
•
the Quality Account is not consistent in all material respects with the sources specified in the
Guidance; and
•
the indicators in the Quality Account subject to limited assurance have not been reasonably
stated in all material respects in accordance with the Regulations and the six dimensions of data
quality set out in the Guidance.
Grant Thornton UK LLP
Grant Thornton House
Melton Street
London
NW1 2EP
30 June 2015
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Appendix 5
National Clinical Audit: actions to improve quality
Audit Title
Actions to improve quality
Seizures in Hospitals
The aims of the audit were to describe and understand the organisation of care available for people presenting to
Emergency Departments with seizures and the variations in care actually delivered. The Trust is partially compliant to the
standards audited. The actions put into place include:
Guidelines for management of 1st Fit and Management of Status Epilepticus are available on ED Intranet page and
reinforced through FY2 teaching.
The Trust has appointed a neurology nurse specialist with an aim to improving length of stay and reducing rate of
admissions.
A first Fit Clinic has been established since June 2013.
National Review of asthma deaths
The aim of the NRAD was to understand the circumstances surrounding asthma deaths in the UK, in order to identify
avoidable factors and make recommendations for changes to improve asthma care as well as patient self-management.
The Trust does not have an asthma service but asthma patients and patients discharged from the hospital with
exacerbation of asthma are seen in general respiratory clinics. There are currently no nominated clinical leads for asthma
services for adult and Paediatrics.
National Emergency Laparotomy –
Organisational Report
The self-reported data showed the provision of facilities required to perform emergency laparotomy. A four- tier surgical
rota is in place during the day and three-tier at night. Critical care and outreach services are staffed at adequate levels to
ensure 24-hour specialist input. In response to this audit:
The radiology department have submitted a business case to set a new interventional suite and on getting an out of
hour’s service up and running where the interventional radiologists are partnered with Epsom and St Helier NHS trust to
form a sustainable rota.
NHS Organ donation report – NHS Blood
and Transplant
Between 1 April 2013 and 31 March 2014, Croydon Health Services NHS Trust had one deceased solid organ donor,
resulting in 3 patients receiving a transplant. 4 organs were donated and all were transplanted. 100% referral rate has
been achieved again over the last year for potential donation after brain stem death (DBD) donors.
Following on from this audit, CUH has been highlighted as one of 2 Trusts in the South East to enter the DonaTE
programme which is a 4 year programme of research funded by the NIHR (National Institute for Health Research) which
aims to reduce barriers to deceased organ donation among minority ethnic groups in the UK.
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National Care of the Dying –
Organisational report
The Trust has achieved the Key Performance Indicator for access to information relating to death and dying, continuing
education and training, Trust Board representation and planning for the care of the dying, clinical protocols for the
prescription of medications for the five key symptoms, clinical provision/protocols promoting patient privacy, dignity and
respect, up to and including after the death of the patient.
A 6 day/week 9-5 service has been established since this audit was undertaken.
National Care of the Dying – Clinical
KPIs
The Trust has fully achieved 7 of the 10 Clinical KPI’s and partially achieved 3. In response to the report:
A prescribing order set has been developed on Cerner for 5 common symptoms that may develop during the dying
phase with pharmacy and the Cerner team.
Review of interventions during dying phase, nutritional and hydration requirements and care after death will be included
as part of the new end-of- life-care Cerner template.
NCEPOD- Tracheostomy Report
Trust participated in the NCEPOD Tracheostomy study during 2014-15. Capnography is now available at each bed space
in critical care and is continuously used when patients are ventilator dependent.
Actions are underway by the Outreach Team to implement the recommendations made by the National Tracheostomy
Safety Project to maintain an essential box of equipment which is sufficiently portable to be moved around with the
patient.
Awareness has been raised among relevant staff to report unplanned tube changes as critical incidents at departmental
meeting.
IBD Inpatient Care audit
All outpatients with ulcerative colitis have their disease activity accurately assessed using symptoms and faecal
calprotectin, and treatment initiated or escalated in those with active disease. Following on from this audit, action have
been put into place to ensure:
Patients referred to the IBD nurse during admission are seen by the IBD nurse.
Contact details are also provided to patients for the IBD service so patients can access post discharge advice and fast
tracking to clinic if required.
Bone protection is prescribed for all patients requiring corticosteroids, and patients are considered for Azathioprine if
they are known to be on long term steroids
National Diabetes Inpatient Audit
The Trust was found to be partially compliant to the standards audited. Following on from this audit, actions put into
place include:
Diabetic patients from A& E observation ward and AMU are prioritised and seen on the same day to allow discharge/
prevent unnecessary admission.
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All diabetic patients referred to Diabetic Specialist Nursing who were administering insulin prior to admission are
assessed to ensure their technique is safe to continue and this is documented on Cerner.
Teaching sessions are in place for Health Care Assistants on management of hypoglycaemia and for trained nurses on
the administration of Insulin.
There is a plan in place for Diabetic Specialist Nursing to introduce and manage diabetes link nurse roles for ward staff
to further improve ward staff awareness.
Weekly joint diabetes/renal Clinic and weekly joint diabetes/vascular clinic are now in place.
National Heavy Menstrual Bleeding
Audit
The Trust has a below average waiting time between referral from GP to first outpatient clinic visit in comparison with
national findings.
The Trust does not have a dedicated ‘one-stop’ clinic for heavy menstrual bleeding, but since this audit, all women that
are referred by their GP are channelled to the intermediate gynaecology clinic, where diagnosis and treatment planning
occurs.
Women on average wait 2-4 weeks for an appointment for the intermediate gynaecology clinic - a recent survey 83.3 %
of the women are satisfied with the care received in the hospital compared to a national mean of 81%.
CEM Sepsis and Septic shock
The Trust was partially compliant to the standards audited. Following on from the recommendation of this audit:
A sepsis task force is now in place
Targeted training sessions were held on the recognition of sepsis and empowerment of junior doctors and nurses during
nurses teaching and doctor training days.
A sepsis recognition algorithm has been implemented via Cerner. This looks at patient observations and bloods to target
a response for Cerner to produce a sepsis alert, this in keeping with the NPSA gold standard recommendations and has
been produced and is active in Cerner.
A sepsis box in Cerner to allow easy access to antibiotics and fluids has been introduced.
Falls and Fragility, Fracture Audit
Programme – National Hip Fracture
Database
The Trust performance is above the national average for surgery on the day of or day after admission, senior geriatric
review within 72hrs of admission, abbreviated mental test performed, specialist falls assessment performed, bone health
medication assessment performed, return home from home within 30 days and best practice tariff attainment. The Trust
was commended for achieving a high home from home within 30 days.
National Joint Registry
The numbers of cases in CHS that are applicable to be entered on the National Joint Registry System (NJR) are low. The
Trust percentage is low for cases submitted to the NJR with patient consent for participation in audit confirmed. Almost
all of the cases entered for the NJR are trauma cases and are rarely, if ever, consented by surgeons for participation in
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NJR. In response to the audit results:
These issues were highlighted to the NJR area representative, who agreed that it is not expected for trauma hip
operations to achieve a high rate of compliance for consenting to participate in the audit.
The Trust will continue to participate in this audit, and put actions in place around recommendations to improve patient
care when they are made.
Inflammatory Bowel Disease - Biologics
The Trust is partially compliant to the standards audited. As per the recommendations, disease activity is routinely
assessed at baseline and again at 3 and 12-­‐month follow-­‐up; this measure forms an important part of objective
assessment of response to treatment and the quality of care provided by the IBD service. Following on from this audit,
the actions included:
The recommendation for putting 160/80 mg of adalimumab into use for induction therapy is now in place at the Trust.
Work is in progress for clinicians to consider stopping 5-­‐aminosalicylic acid (5-­‐ASA) drugs in patients on biologics with
Crohn’s disease.
Inflammatory Bowel Disease Organisational
This audit found that new referrals for IBD patients are seen within 5-7 working days and relapsing patients who contact
the helpline are seen within 5-7 working day. Nutritional assessments are done on admission and dietetic support for
IBD patients is already in place.
Following on from the audit, it was found that formal psychological support is not provided within the IBD Service; very
few hospitals have managed to establish a dedicated psychological support service. Patients are counselled as far as
possible in clinical setting as part of nurse role, since the results, patients are also now signposted to charity services that
can help with counselling.
National Paediatric Diabetes Audit
The national paediatric audit report highlights the main findings on the quality of care for children and young people
with diabetes. Following on from the audit:
The paediatric diabetes service has established an of Out of Hours rota with St George’s NHS Foundation Trust to
provide direct telephone access to expert advice 24/7.
The policy for escalating management of patients with HbA1c greater than 75mmol/mol has been revised.
And information and demonstration sessions on pump therapy have been undertaken.
Neonatal National Audit Programme
(NNAP)
The key aims of the audit are to assess whether babies admitted to Neonatal Units in England and Wales receive
consistent care in relation to the audit questions; and to identify areas for quality improvement in NNUs in relation to
delivery and outcomes of care. The Trust performance for first Retinopathy of Prematurity (ROP) screening in accordance
with the current guideline recommendations has improved from 40% in 2013 to 94% during 2014. Since the audit, it
has been implemented all eligible babies’ temperatures were taken within an hour of birth.
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National Pregnancy in Diabetes Audit
The Trust is compliant to the standards audited in the National Pregnancy in Diabetes Audit. Training of GP’s about
complications of diabetes in pregnancy is on-going where early referral of pregnant women to diabetic midwife for
booking is re-in forced. Since this audit, patient education programmes for women with Type 2 diabetes that are already
in place will be on-going.
NCEPOD – Lower Limb Amputation
The Trust participated in the NCEPOD –Lower Limb Amputation Study. The aim of the study was to explore remediable
factors in the process of care of patients undergoing major lower limb amputation. The national report is currently under
review by the Lead Clinician.
Epilepsy -12
The Trust met 11 out of the 12 performance indicators for the Epilepsy 12 audit. The Trust is a negative outlier for
provision of an Epilepsy Specialist Nurse. The possibility of employing full or part time epilepsy specialist nurse is being
explored. Since the audit results:
A joint paediatric neurology clinic with visiting paediatric neurologist from SGH is held 8 times a year. These are full day
clinics where complex patient referred are seen together with local paediatrician.
Guidelines are also available within the Trust regarding the first fit referral pathway and assessment.
National Prostate Cancer –
Organisational
The Trust is participating in the National Prostate Cancer Audit for patients’ diagnosed from April 2014 and is regularly
submitting data. There is availability of personal support services including cancer advisory centres, sexual function and
continence advice, and psychological counselling for prostate cancer patients. Multi-parametric MRI is available to
patients on the prostate cancer pathway. Patients have access to a joint clinic with a surgeon, an oncologist and a
Clinical Nurse Specialist to discuss their treatment options. Following on from the findings of the audit:
A business case is planned for a dedicated prostate cancer nurse specialist with background in uro-oncology. Patients are
currently seen by the Uro-oncology nurse.
Chronic Obstructive Pulmonary Disease Organisational
The report presents results from the second element of the national COPD secondary care audit, a clinical audit of COPD
exacerbations admitted to acute NHS units in England and Wales during February to April 2014. The audit assessed
performance against key quality standards, clinical guidelines and accepted best practice for COPD management. The
report has been sent to the Lead Clinician for action plans and comments.
National Oesophago-Gastric Cancer
audit
The Trust was found to be compliant to the standards audited in the National Oesophago-gastric Cancer audit.
Patients diagnosed with HGD of the oesophagus are referred to St Thomas’ Hospital onto London Cancer Alliance
Pathway. Ablative therapy is carried out at St Thomas’.
A local audit is planned to be to be carried out on early cancers in 2015-16
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MBBRACE
The report has identified clear opportunities to improve care in the future. Basic observations and rapid actions have the
potential to save women’s lives, particularly in relation to sepsis. Events leading to catastrophic haemorrhage can be
prevented by cautious and appropriate use of uterotonic drugs. Above all, there is a need for coordinated and concerted
action at all levels to improve the care of women with medical complications before, during and after pregnancy. CHS
has developed an action plan in response to this publication to include amending the booking guideline and to develop
a guideline for epilepsy in pregnancy – in partnership with the neurology team. In response to this audit:
Guidelines on peri-mortem caesarean section and recognition of the pregnant and recently delivered women are
currently being amended to reflect the recommendations of this report.
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Appendix 6
Local Clinical Audit: actions to improve quality
Audit Title
Actions to improve quality
Acute Testicular pain
Further education regarding triage times, assessing doctor and referrals
Admissions to the Neonatal Unit of term infants
No further action – audit compliant with standards
An audit to assess the adherence to the Royal
College of Pathologists minimum dataset for
reporting testicular cancer
Antenatal Booking Audit
Consultants to include TNM staging in the minimum dataset for testicular cancer
From September 1st 2014 a women’s only antenatal visit will be mandatory at 16/40 to ensure routine enquiry
regarding domestic violence can take place.
March 2015 Audit of Care of women with complex social factors will include Domestic violence- Routine enquiry as an
aspect of the audit. Will be performed 6 months after implementation of new guideline. (August 2014)
All midwives email highlighting the importance of documentation at booking
Ensure audit report is disseminated to all community midwifery staff at team meetings by emailing it to the team leaders
Present audit findings at Maternity Clinical governance meeting
Audit of Appropriate Attire on Discharge
On-going discharge planning training available, senior nurses to promote training.
Audit of clinical audit process
Review and rewrite the Clinical audit policy which is due for review in March 2015.
Audit of compliance of antenatal steroids in
preterm deliveries
No further action – audit compliant with standards
Audit of ED Intra-Osseous Access Insertions
Undertake training sessions for ED Doctors and Nurses to include awareness of EZIO pro-forma
Utilise EZIO in all cardiac arrests where no vascular access is in-situ, or concerns regarding patency of access are present
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Audit of outcome of gestational diabetes in
2013 for Type I and II
No further action – audit compliant with standards
Audit of paper nursing care plans
As of March 2015 all care plans are now on Cerner, 2015-16 will look at the effectiveness of care plans using Cerner
Audit on Emergency abdominal CT
Defined consultant cover from 07:00-09:00
Re-enforce what is required from A&E e.g. correct and complete trauma paperwork, nurse escorts
Radiology department porters
Audit to monitor compliance with the
implementation of Best Practice Policy - National
Institute for Clinical Excellence (NICE) Guidance
Continue to report to DPQB and CGQ the level of compliance of guidance with NICE guidance on monthly basis
Caesarean section rates in Maternity from June
to August 2014
Reminder to be sent to midwives to document indication of C/S on Protos delivery summary to improve data quality.
Comparison of clinical factors for patients
discharged with a satisfactory or unsatisfactory
treatment outcome.
No further action – audit compliant with standards
Current practice in thromboprophylaxis with
subcutaneous heparin in high risk day surgery
patients
The pre-operative assessment nurses will be given teaching on VTE. A scoring system can be introduced. They can give
out the VTE leaflets during the pre-operative assessment.
Continue to escalate as per policy if no response received
Day surgery nurses will show patients how to self-administer the subcutaneous injection before discharge. TTO’s will be
supplied by pharmacy. Patients are to be sent home with written instructions
The ensure GP’s are made aware of the patient being discharged on heparin injections.
Discharge summaries CQUIN (quarterly)
Regular monitoring and feedback of discharge summary quality/sending of summaries
Development of a “discharge summary feedback form” for individual summaries where a poor discharge summary has
been identified (trial to start in the community)
Targeted teaching to those wards identified as struggling to complete process
Teaching to Fy1 has been done, this will need to be on-going to all who do discharge summaries
DNACPR (quarterly audit)
Formal nursing ward handovers to be standardised to include the resuscitation status of each patient
Consultants to ensure full adherence to current Resuscitation Policy regarding counter signing DNACPR forms within 48
90
hours of the original decision-this to be addressed by Cerner migration.
All medical staff to document discussions had with patients regarding the decision to make a patient not for active
resuscitation
Where possible and/or appropriate, medical staff to document any discussion had with patients’ relatives/Welfare
Attorney-if a conversation with the relatives/Welfare Attorney is not appropriate and/or not possible this should also be
documented-this to be addressed by Cerner migration.
DNACPR and the communication of decisions
relating to resuscitation, are we getting it right
in the era of modernisation
All CPR statuses should match on both paper form and CERNER
All DNACPR decisions should have a documented discussion and CPR form should be reviewed and countersigned by
consultant within 12 hours.
CPR status should be an active part of weekly MDT meeting
It is the responsibility of the doctor changing the CPR status to inform the nurse in charge of the change
Nursing team to ensure CPR status is part of their daily handover.
Documentation for neuraxial anaesthesia for
patients undergoing obstetric intervention
The introduction of standardised pre labelled neuraxial anaesthesia risk documentation stickers in obstetric unit based on
obstetric guidelines.
The labels have been printed and will be used from now on.
Re audit of the neuraxial documentation after six-month period to see the efficacy of the stickers and to close the audit
loop.
Documentation of consent forms audit
Consent training to relevant staff
Policy author to review policy and consider being more specific as to how consent forms are to be completed
For future re-audits, disseminate the audit tool for consultation and amendments if required
Consent forms to be considered for Cerner
Colorectal speciality to review current consent form in use
ED initiated non-invasive ventilation
All NIV forms must be fully completed
Improve documentation of safe transfer checklist to maintain patient safety in this group
Evidence of CCOT notification prior to all ward transfers
Examination of the newborn: Routine
Add discussion of the use of Routine Neonatal SATS monitoring to the Agenda August Practice review and guidelines
91
Saturation monitoring and the detection of
congenital Heart defects
group.
Failed Instrumental delivery in Maternity
No further action – audit compliant with standards
GP Referrals for Pregnancy Booking Audit
From September 1st 2014 a women’s only antenatal visit will be mandatory at 16/40 to ensure routine enquiry
regarding domestic violence can take place.
March 2015 Audit of Care of women with complex social factors will include Domestic violence- Routine enquiry as an
aspect of the audit. Will be performed 6 months after implementation of new guideline. (August 2014)
All midwives email highlighting the importance of documentation at booking
Hydration Unit for Hyperemesis Gravidarum
Further training and consideration of extended opening hours are required to improve adherence to guideline and
reduce acute admissions for hyperemesis.
Major Obstetric Haemorrhage
Consider amending MOH proforma to include information in recommendations to improve documentation
Monitoring of Paed Sickle cell patients on
Hydroxyurea
On-going monitoring of blood tests is 100% both on fortnight blood tests and post dose re-adjustment. Patients are
clinically and haematologically safe to continue treatment. Adjustments to the care are required on the key points i.e.
fortnight and three monthly checks.
Mother and Baby contact audit
Midwives need more training in the importance of accurate documentation regarding skin to skin and the first feed.
Health professionals need to be aware of the importance of unhurried skin to skin.
All staff to be aware of the benefits of skin to skin for all babies, not just breastfeeding babies.
Patient Identification Audit
Patient Identification is the responsibility of all Trust employees. At the point it is identified that a patient does not have a
patient identification wrist band on their person this must be immediately challenged with the clinical staff responsible
for their care.
Positive patient identification must be confirmed and a wristband must be printed and provided to the patient. In the
event a patient refuses to wear the wristband, this must be documented within their notes, according to trust policy.
Perioperative temperature management
Discuss with all wards and staff undertaking theatre checklists to ensure that all the patients have a temperature
documented.
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Discuss the importance of this to anaesthetists at the next clinical governance meeting where the results will be
presented
All patients at risk of hypothermia should be identified during team brief. All staff in theatre should be proactive about
warming and it is part of the WHO theatre checklist.
Discuss the results of the audit with recovery staff. Encourage more frequent measurement and documentation of
temperatures. Encourage the use of warm air devices.
Quality of Intraoperative cerebral protection
To increase awareness of implications of hypotension, hypocapnoea in this patient population, and benefits of DOA
monitoring.
Resuscitation Trolley Audit (quarterly)
Quarterly audits and reports on resuscitation trolley compliance following the above template.
Increased ward based teaching to departments/areas that have challenges
New ward based resuscitation resource folder to be implemented in quarter three and evaluated
Ward based simulations to test local response to emergency situations exploring any organic issues
Review of recordkeeping of immunisations
status of Croydon looked after children
Update LAC status using weekly snapshot of those who have become looked after, and those who have left care.
Request for immunisation GP records made at time of health assessment appointment request – foster carer and GP
letter.
Immunisations checked at each health assessment and LAC review by IROs
The importance of immunisations discussed at each health assessment and at any relevant opportunities
Risk Assessment and Prophylasis for Venous
Thrombo-embolism in Trauma and Othopaedics
No further action – audit compliant with standards
Risk assessment and prevention of VTE in
Maternity
Re-audit the compliance with antenatal VTE risk assessment once Cerner in place
Severe Sepsis and Septic Shock audit
Email standards and audit to current A&E Doctors, along with a teaching session
Clearer, eye catching, simple messaged posters in key areas on A&E
On-going MDT awareness
Split-Bolus Nephrourographic CT - are we
getting optimum opacification?
Protocols adjusted with radiographers in CT: Bolus of 40ml then 60ml to be used, and patients scanned supine without
rolling.
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Protocol using split bolus techinique to be reserved for young patients <50 which low likelihood of malignancy
Staff awareness of Mental Capacity Act and
Deprivation of Liberty safeguards
Increase the number in house MCA and DOLS Master Classes; include a SLAM psychiatrist slot and an assessment
scenario.
Provide laminated DOLS Flowchart Poster for all elderly care, surgical and medical wards
Copies of the code of Practice for MCA and DOLS on elderly care, surgical and medical wards
Include MCA and DOLS awareness for FY1s and FY2s
Mini audits to be carried by nurse managers
Stillbirth Audit
Audit a/n notes looking at fundal height documentation
Further Audit looking at IUGR in relation to stillbirth over last 10 years
Discussion to be had re individual growth charts and dopplers due to a common factor being placental issues and IUGR
Supervisor of Midwives Record Keeping Audit
No further action – audit compliant with standards
Supplementation of Breastfed Babies
Shared learning from audit within the maternity newsletter, on the mandatory study day and BFI study day, re-enforcing
the need for evidence-based/consistent advice to be given.
Continue to monitor BFI education
Ensuring completion of the paediatric induction/ e learning session.
Inform in-patient matron/Postnatal ward sister of findings and to ensure full required documentation is completed at all
times.
Continue BFI education.
Review method of documentation and whether is fit for purpose.
The management of Gonorrhoea at Croydon
University Hospital
Better documentation around:
Reason why patient did not see Health Advisor
Abstinence from sex
Offering of information leaflet
Partner notification:
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Greater use of Partner Notifications tab
Documenting outcome of agreed contact(s) action(s)
Verification i.e. confirming contact attendance by checking records in your own service, or by contacting other services
where contacts may have attended
Time elapsed to endoscopy in patients with
acute Upper GI Bleeds
Aim to scope ALL patients within 24 hours
Improve post endoscopy documentation on all patients
Junior doctors to request on correct form
All available slots on endoscopy lists to be utilised for GI bleeds
Post endoscopy Rockall score compulsory on endoscopy reporting system
Tongue Tie Audit
Follow up procedure be extended to include a 6 week post procedure contact
Practitioner at procedure to routinely discuss follows up procedure with parents.
Standardised feeding categories pre and post procedure to be added to the referral form and used when making
contact for follow up.
Transient loss of Consciousness (TLoC) - audit of
the clinic pathway
Raise awareness of First Fit Clinic pathway
Make appointments while patient in A&E
Give date and time in writing
New text or email reminder
2 appointments per week is insufficient to achieve < 2 week wait.
Increase to 3 appointments per week
Raise awareness of “Management of first seizure in the ED” protocol - in First Fit Pack
Modify protocol and referral form to include reminder about eyewitness account
Driving and safety information sheet included in First Fit Pack
New tick box on referral form to confirm that it has been given to patient
Please document: e.g. “Told not to drive until sees neurologist. Given seizure safety sheet.”
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Trichomonas vaginalis audit
No further action – audit compliant with standards
Trust-wide Record-keeping audit
Findings of the audit to be reported through DPQB and disseminated to individual teams – to improve practice through
staff/team/departmental meetings and clinical governance sessions.
Uterine Fibroid Embolisation - Technical aspects
audit
Radiologists should remain mindful of radiation dose and try to minimise digital subtraction angiography.
Ward interpretation and use of emergency
feeding regimen
Swift action from nursing leadership is recommended to revisit local process and support those who require more
support so that compliance with policy improves. Shared learning from Sisters on the good practice ward with the
sisters of poor performers may be helpful.
All MUST scores to be recorded accurately and electronically on CERNER as policy standard.
It should be noted that weights are being recorded on a regular basis for patients within the hospital but unless the
MUST score is completed it will not be recorded as a measure of MUST and therefore draw low MUST completion scores
for that ward.
WHO checklist (quarterly for all applicable areas)
To continue to achieve full compliance in all areas and arrange another quarterly audit in June 2015 for day surgery and
main theatres.
Discuss at the Surgery Quality Board meeting
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Appendix 7
National Confidential Enquiries: actions to improve quality
Title
Actions to improve quality
Sepsis
Report not yet published
Gastro-intestinal Haemorrhage
Report not yet published
Lower Limb Amputation
Clinical lead has a deadline of 30th June 2015 to form an action plan
Tracheostomy Care
Staff to undergo training to re-enforce that all staff to record tracheostomy insertions on Cerner
Staff to undergo training regarding core competences for the care of tracheostomy patients, including resuscitation
All unplanned tube changes to be reported locally as critical incidents and investigated to ensure that lessons are learned
and reduce the risk of future events
Trust to put in place a protocol and mandatory training for tracheostomy care including guidance on humidification, cuff
pressure, monitoring and cleaning of the inner cannula and resuscitation
Trust to implement and maintain an essential box of equipment which is sufficiently portable to be moved around with
the patient (as recommended by the National Tracheostomy Safety Project)
Bedside staff who care for tracheostomy patients to undergo training to ensure competency in recognising and
managing common airway complications including tube obstruction or displacements and as described by the National
Tracheostomy Safety Project algorithms.
Emergency action plans must clearly reflect the escalation policy in order to summon senior staff in the event of a
difficult airway event 97
Appendix 8: MRSA bacteraemia improvement work at CUH 2008 – 2015
98
Appendix 9: HAI C.difficile improvement work at CUH 2008 - 2014
99
Appendix 10: Patient Safety Alerts 2014-15
Reference
Alert Title
Issue Date
Response
Deadline
NHS/PSA/D/2014/010
* Standardising the early identification of Acute
Kidney Injury
09-Jun-14
Action Required: Ongoing
09-Mar-15
NHS/PSA/D/2014/011
Legionella and heated birthing pools filled in
advance of labour in home settings
17-Jun-14
Action Completed
30-Jun-14
NHS/PSA/R/2014/015
Resources to support the prompt recognition of
sepsis and the rapid initiation of treatment
02-Sep-14
Action Completed
31-Oct-14
NHS/PSA/W/2014/007
Minimising risks of omitted and delayed medicines
for patients receiving homecare services
10-Apr-14
Action Completed
09-May-14
NHS/PSA/W/2014/008
Residual anaesthetic drugs in cannulae and
intravenous lines
14-Apr-14
Action Completed
13-May-14
NHS/PSA/W/2014/009
Risk of using vacuum and suction drains when not
clinically indicated
06-Jun-14
Action Completed
04-Jul-14
NHS/PSA/W/2014/012
Risk of harm relating to interpretation and action on
PCR results in pregnant women
23-Jun-14
Action Completed
31-Jul-14
NHS/PSA/W/2014/013
Risk of inadvertently cutting in-line (or closed)
suction catheters
17-Jul-14
Action Completed
14-Aug-14
NHS/PSA/W/2014/014
Risks arising from breakdown and failure to act on
communication during handover at the time of disc
...
29-Aug-14
Action Completed
13-Oct-14
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Reference
Alert Title
Issue Date
Response
Deadline
NHS/PSA/W/2014/016
Risk of distress and death from inappropriate doses
of naloxone in patients on long-term opioid/opia ...
20-Nov-14
Action Completed
22-Dec-14
NHS/PSA/W/2014/016R
Risk of distress and death from inappropriate doses
of naloxone in patients on long-term opioid/opiate
...
20-Nov-14
Action Completed
22-Dec-14
NHS/PSA/W/2014/017
Risk of death and serious harm from delays in
recognising and treating ingestion of button
batteries
19-Dec-14
Action Completed
19-Jan-15
NHS/PSA/W/2014/18
Risk of death and serious harm from accidental
ingestion of potassium permanganate preparations
22-Dec-14
Action Completed
22-Jan-15
NHS/PSA/W/2015/001
Harm from using Low Molecular Weight Heparins
when contraindicated
19-Jan-15
Action Completed
02-Mar-15
NHS/PSA/W/2015/002
Risk of death from asphyxiation by accidental
ingestion of fluid/food thickening powder
05-Feb-15
Action Completed
19-Mar-15
NHS/PSA/W/2015/003
Risk of severe harm and death from unintentional
interruption of non-invasive ventilation
13-Feb-15
Action Completed
27-Mar-15
NHS/PSA/W/2015/004
Managing risks during the transition period to new
ISO connectors for medical devices
27-Mar-15
Action Required: Ongoing
08-May-15
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Appendix 11: Glossary
Acute Trust
A trust is an NHS organisation responsible for providing a group of
healthcare services. An acute trust provides hospital services (but not
mental health hospital services, which are provided by a mental health
trust).
Audit
Commission
The Audit Commission regulates the proper control of public finances
by local authorities and the NHS in England and Wales. The
Commission audits NHS trusts, primary care trusts and strategic health
authorities to review the quality of their financial systems. It also
publishes independent reports which highlight risks and good practice
to improve the quality of financial management in the health service,
and, working with the Care Quality Commission, undertakes national
value-for-money studies. Visit: www.audit-commission.gov.uk
Board (of
trust)
The Trust Board is accountable for setting the strategic direction of the
Trust, monitoring performance against objectives, ensuring high
standards of corporate governance and helping to promote links
between the Trust and the community.
Care Quality
Commission
The Care Quality Commission (CQC) replaced the Healthcare
Commission, Mental Health Act Commission for Social Care Inspection
in April 2009. The CQC is the independent regulator of health and
social care in England. It regulates health and adult social care services,
whether provided by the NHS, local authorities, private companies or
voluntary organisations. Visit: www.cqc.org.uk
Cerner
millennium
system (CRS)
Cerner millennium is the newly introduced IT system at Croydon Health
Services NHS Trust. This is an electronic system that captures patient
data.
Clinical Audit
Clinical audit measures the quality of care and services against agreed
standards and suggests or makes improvements where necessary.
Clinical
Coding
Clinical Coding Officers are responsible for assigning ‘codes’ to all
inpatient and day case episodes They use special classifications which
are assigned to and reflect the full range of diagnosis (diagnostic
coding) and procedures (procedural coding) carried out by providers
and enter these codes onto the Patient Administration System.
The coding process enables patient information to be easily sorted for
statistical analysis. When complete, codes represent an accurate
translation of the statements or terminology used by the clinician and
provides a complete picture of the patient’s care.
102
Clinical
Directorate
During 2011/12 Croydon Health Services NHS Trust clinical services
were organised into four directorates: Adult Care Pathways, Cancer
and Core functions, Critical Care and Surgery and Family Services.
Clostridium
difficile or C.
Difficile
Clostridium difficile also known as C.difficle or C. diff, is a gram
positive bacteria that causes diarrhea and other intestinal disease when
competing bacteria in a patient or persons gut are wiped out by
antibiotics.
C. difficile infection can range in severity from asymptomatic to severe
and life-threatening, especially among the elderly. People are most
often nosocomially infected in hospitals, nursing homes, or other
institutions, although C. difficile infection in the community and
outpatient setting is increasing.
Commissione
rs of services
Organisations that buy services on behalf of the people living in the
area that they cover. This may be for a population as a whole, or for
individuals who need specific care, treatment and support. For the
NHS, this is done by primary care trusts and for social care by local
authorities. The host commissioner was NHS Croydon (Croydon PCT)
and their delegated managerial function is led by the SWL Acute
Commissioning Unit (SWL ACU). Please note that during 2012/13 local
implementation of the Health and Social Care Act was undertaken and
Croydon Clinical Commissioning group has now been established.
From1 April 2013 this is now a statutory commissioning authority.
Commissioni
ng for Quality
and
Innovation
High Quality Care for All included a commitment to make a proportion
of providers’ income conditional on quality and innovation, through the
Commissioning for Quality and Innovation (CQUIN) payment
framework. Visit:www.dh.gov.uk/en/ Publications and
statistics/Publications/ PublicationsPolicyAndGuidance/DH_09 1443
Complaint
An expression of dissatisfaction with something. This can relate to any
aspect of a person’s care, treatment or support and can be expressed
orally, in gesture or in writing.
Croydon
Clinical
Commissioni
ng Group
(CCG)
The CCG became legally responsible for commissioning/buying
healthcare services for Croydon residents from 1st April 2013 as
authorised by NHS England
Culture
Learned attitudes, beliefs and values that define a group or groups of
people.
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Datix
This is the name of the incident reporting system at Croydon Health
Services NHS Trust
Department
of Health
The Department of Health is a department of the UK government but
with responsibility for government policy for England alone on health,
social care and the NHS.
Dignity
Dignity is concerned with how people feel, think and behave in relation
to the worth or value that they place on themselves and others. To
treat someone with dignity is to treat them as being of worth and
respect them as a valued person, taking account of their individual
views and beliefs.
Discharge
The point at which a patient leaves hospital to return home or be
transferred to another service, or the formal conclusion of a service
provided to a person who uses services.
EWS
This is the Early Warning System is based on vital signs such as blood
pressure, heart and breathing rates
Family and
Friends Test
Introduced in 2013 it is an opportunity for family and friends to give
feedback to hospitals regarding their care and experience
Foundation
trust
A type of NHS trust in England that has been created to devolve
decision-making from central government control to local organisations
and communities so they are more responsive to the needs and wishes
of their local people. NHS foundation trusts provide and develop
healthcare according to core NHS principles – free care, based on need
and not on ability to pay. NHS foundation trusts have members drawn
from patients, the public and staff, and are governed by a board of
governors comprising people elected from and by the membership
base.
Global
Trigger Tool
(GTT audit)
The Global Trigger Tool is a recognised and validated audit tool
developed by the Institute for Healthcare Improvement (IHI) In Boston
USA. It can be used as part of an organisation’s safety improvement
programme to identify and so learn about harm and safety incidents
which occur as part of the patient’s treatment. Barts and The London
NHS Trust has been undertaking GTT auditing since 2008.
Healthcare
Healthcare includes all forms of healthcare provided for individuals,
whether relating to physical or mental health, and includes procedures
that are similar to forms of medical or surgical care but are not
provided in connection with a medical condition, for example cosmetic
surgery.
Healthcareassociated
An avoidable infection that occurs as a result of the healthcare that a
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infection
person receives.
Hospital
Episode
Statistics
Hospital Episode Statistics is the national statistical data warehouse for
England of the care provided by NHS hospitals and for NHS hospital
patients treated elsewhere.
Indicators
The Indicators for Quality Improvement (IQI) are a resource for local
clinical teams providing a set of robust indicators which could be used
for local quality improvement and as a source of indicators for local
benchmarking. The IQI can be found on the NHS Information Centre
website at:www.ic.nhs.uk/services/ measuring-for-quality improvement
for Quality
Improvement
Information
Governance
The structures, policies and practice to ensure the confidentiality and
security of health and social care service records, especially clinical
records which enable the ethical use for the benefit of the individual to
whom they relate and for the public good.
Quality and
Clinical
Governance
Committee
This committee monitors, reviews and reports on the quality of services
provided by the Trust. This includes the review of: Governance, risk
management and internal control systems to ensure that the Trust’s
services deliver safe, high quality, patient-centred care. Performance
against internal and external quality improvement targets and followup whenever required. Progress in implementing action plans to
address shortcomings in the quality of services – if any have been
identified.
HealthWatch
HealthWatch is made of individuals and community groups which work
together to improve local services. Their role is to find out what the
public like and dislike about local health and social care. They will then
work with the people who plan and run these services to improve
them. This may involve talking directly to healthcare professionals
about a service that is not being offered or suggesting ways in which
an existing service could be made better. HealthWatch also have
powers to help with the tasks and to make sure changes happen.
MRSA
Methicillin-Resistant Staphylococcus Aureus (MRSA) is a bacterium
responsible for several difficult-to-treat infections in humans. MRSA is,
by definition, any strain of Staphylococcus aureus bacteria that has
developed resistance to antibiotics including the penicillins and the
cephalosporins. MRSA is especially troublesome in hospitals, where
patients with open wounds, invasive devices and weakened immune
systems are at greater risk of infection than the general public.
Malnutrition
Universal
Screening
Tool (MUST)
‘MUST’ is a five-step screening tool to identify adults, who are
malnourished, at risk of malnutrition (undernutrition), or obese. It also
includes management guidelines which can be used to develop a care
plan.
105
National
Confidential
Enquiry into
Patient
Outcome and
Death NCEPOD
The National Confidential Enquiry into Patient Outcome and Death
(NCEPOD) reviews clinical practice and identifies potentially remediable
factors in the practice of anaesthesia and surgical and medical
treatment. Its purpose is to assist in maintaining and improving
standards of medical and surgical care for the benefit of the public. It
does this by reviewing the management of patients and undertaking
confidential surveys and research, the results of which are then
published. Clinicians at Croydon Health Services NHS Trust participate
in national enquiries and review the published reports to make sure any
recommendations are put in place.
National
Institute for
Health and
Clinical
excellence
The National Institute for Health and Clinical Excellence is an
independent organisation responsible for providing national guidance
on promoting good health and preventing and treating ill health. Visit:
www.nice.org.uk
National
Patient Safety
Agency
The National Patient Safety Agency is an arms-length body of the
Department of Health, responsible or promoting patient safety
wherever the NHS provides care. Visit: www.npsa.nhs.uk
NHS Number
This is the national unique patient identifier that makes it possible to
share patient information across the whole of the NHS safely, efficiently
and accurately. The NHS Number is fundamental to the development of
the National Programme for IT.
NHS
Litigation
Authority
(NHSLA)
The NHSLA is a special health authority in the NHS responsible for
handling negligence claims made against NHS bodies in England. In
addition it has developed an active risk management programme to
raise NHS safety standards and reduce the incidence of negligence. It
also monitors human rights case law on behalf of the NHS, coordinates claims for equal pay in the NHS and handles Family Health
Service appeals (i.e. disputes between doctors, dentists, opticians and
pharmacists and NHS Primary Care Trusts).
Overview
Since January 2003, every local authority with responsibilities for social
services (150 in all) have had the power to scrutinise local health
services. Overview and scrutiny committees take on the role of scrutiny
of the NHS – not just major changes but the ongoing operation and
planning of services. They bring democratic accountability into
healthcare decisions and make the NHS more publicly accountable and
responsive to local communities.
and scrutiny
committees
Patient
A person who receives services provided in the carrying on of a
regulated activity. This is the definition of “service user” provided in the
Health and Social Care Act 2008 (Regulated Activities) Regulations
2010.
Patient and
This used to be called Patient and Public Involvement (PPI) but has
106
Public Voice
recently been renamed. It highlights ways in which the public and
patients are involved in a trusts patient care
Periodic
reviews
Periodic reviews are reviews of health services carried out by the Care
Quality Commission (CQC). The term ‘review’ refers to an assessment
of the quality of a service or the impact of a range of commissioned
services, using the information that the CQC holds about them,
including the views of people who use those services. Visit:
www.cqc.org.uk/guidanceforprofessionals/healthcare/nhsstaff/periodicr
eview2009/1 0.cfm
Picker
Institute UK
The Picker Institute Europe is a not-for-profit organisation that supports
the healthcare sector to help make patients’ views count in healthcare.
It works to build and use evidence to champion the best possible
patient-centred care working with patients, professionals and policy
makers to achieve the highest standards of patient experience. In
Europe and the UK, Picker research and gather patient’s views of
healthcare using surveys, focus groups and other methods as for
example by supporting the national survey programme in the NHS for
the Care Quality Commission.
Privacy and
dignity
To respect a person’s privacy is to recognise when they wish and need
to be alone (or with family or friends), and protected from others
looking at them or overhearing conversations that they might be
having. It also means respecting their confidentiality and personal
information. To treat someone with dignity is to treat them as being of
worth and respect them as a valued person, taking account of their
individual beliefs
Providers
Providers are the organisations that provide NHS services, for example
NHS trusts and their private or voluntary sector equivalents.
Quality
monitoring
A continuous system of monitoring to ensure that local quality
measures are effective. Quality monitoring is part of quality assurance.
Registration
From April 2009, every NHS trust that provides healthcare directly to
patients must be registered with the Care Quality Commission (CQC).
Research
Clinical research and clinical trials are an everyday part of the NHS. The
people who do research are mostly the same doctors and other health
professionals who treat people. A clinical trial is a particular type of
research that tests one treatment against another. It may involve either
patients or people in good health, or both.
Safeguarding
Ensuring that people live free from harm, abuse and neglect and, in
doing so, protecting their health, wellbeing and human rights.
Children, and adults in vulnerable situations, need to be safeguarded.
For children, safeguarding work focuses more on care and
development; for adults, on independence and choice.
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Secondary
Uses Service
(SUS)
A single repository of person and care event level data relating to the
NHS care of patients, which is used for management and clinical
purposes other than direct patient care. These secondary uses include
healthcare planning, commissioning, public health, clinical audit,
benchmarking, performance improvement, research and clinical
governance. Visit: www.ic.nhs.uk/services/the-secondary-uses-servicesus/using-this-service/ data-quality-dashboards
Adult social
care
Social care includes all forms of personal care and other practical
assistance provided for people who by reason of age, illness, disability,
pregnancy, childbirth, dependence on alcohol or drugs or any other
similar circumstances, are in need of such care or other assistance. For
the purposes of the Care Quality Commission, it only includes care
provided for, or mainly for, people over 18 years old in England. This is
sometimes referred to as adult social care.
ViEWS
VitalPAC Early Warning System is a tool for bedside evaluation
incorporated into VitalPAC. It is based on seven physiological
parameters: pulse; temperature; systolic blood pressure; respiratory
rate; AVPU (the level to which the patient responds), oxygen saturation,
plus the patient’s inspired oxygen requirements.
VitalPAC
An electronic track and trigger system that provides a recording
mechanism for patient’s vital signs and essential screening tools. The
data entered generates an Early Warning Score (EWS) and when
appropriate prompts the clinical practitioner to escalate the patient’s
condition appropriately.
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If you would like this document in another format or
language please contact the communications team by calling
202 8640 3000
Croydon Health Services NHS Trust
Croydon University Hospital
530 London Road
Croydon
CR7 7YE
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