thoughtful
caring
safe
Quality Account 2013/14
CONTENTS
01 Introduction from the Chairman and Chief Executive01
Declaration of Accuracy
03
02 Quality review of 2013/14
04
03 Quality priorities for 2014/15
12
04 Assurance of service quality in 2013/14
17
05 Quality management34
06 Workforce and quality49
07 Research & Innovation51
08Appendices
52
Appendix 1 – Statements of assurance
52
Appendix 2 – Statements of Directors’ responsibilities in
respect of the Quality Account
55
Appendix 3 – NHS Outcomes Framework
56
Appendix 4 – Auditors’ Report
59
Appendix 5 – Peer hospitals
61
Appendix 6 – Glossary of terms
62
01
INTRODUCTION
01
INTRODUCTION
Welcome to our 2013/14 Quality
Account, which describes how well
we did against our quality and
safety standards. For the first time
we publish this Report in the same
month as our Annual Report, which
provides information about how we
are doing in all areas of performance,
including finance.
We have made strong progress against many of the quality
and safety priorities we developed after listening to what
our patients, carers, members and staff told us was most
important to them. The views of our local health and social
care partners and national requirements also influenced
our priorities.
We want this document to be easy to follow. Wherever
possible we show (1) our performance over a number of
years and (2) how we compare to other similar hospitals.
We can confidently say that patients are safer in our care this
year than last and that most have a good experience in our
care. Our infection rates are lower than ever, we had 11.5%
fewer falls, fewer deaths from severe sepsis, and significantly
improved safety in our theatres.
We have expanded the use of the ‘friends and family’ test
to our Emergency and Maternity Departments. We have
consistently been in the top quarter of trusts for response
rates and scores: most of our patients would recommend
our hospitals. This ward-level, near real-time patient feedback
is helping us to respond quickly when there are problems.
In late 2013 a 60-strong Care Quality Commission (CQC)
team inspected each of the care pathways across Queen’s
Medical Centre and Nottingham City Hospital over a fourday period. In February 2014 the CQC published its Report
and concluded we are a ‘good trust’: safe, caring, effective,
responsive and well-led. The CQC commended our hard
working, compassionate and dedicated staff, and observed
many examples of good and excellent practice.
The CQC described two areas where we were non-compliant
with the mandatory standards and need to make quicker
improvement: attendance by staff at mandatory training and
maintenance of medical equipment. They acknowledged
we were working to improve in these areas before their
inspection, but requested our improvement plans were
strengthened. More detailed information about our
inspection is on page 17.
We recognise the importance of improving patient
communication and listening to and responding to feedback.
This includes involving patients and carers better in decisions
about their care: improvements include the roll-out of a new
nurse handover project across every inpatient ward.
Cancelled operations are lower than ever, although we
appreciate that one cancellation is one too many.
‘Better for You,’ our established whole-hospital
transformation programme, continues to deliver
exceptional results, driven by the feedback we receive from
our patients, their loved ones, carers and staff. Over the last
year we have brought together our programme for system
and process redesign (‘Better for You’) and our Learning
and Organisational Development. This is enabling us to
better support all of our improvement work across safety,
experience and effectiveness.
We have continued to renew and update our plans to
support key national developments in the last year. Our
priorities have been influenced by publications including the
Francis, Keogh and Berwick Reviews, and more recently by
our CQC Inspection Report.
For the second year running, staff voted NUH one of the best
trusts in which to work. Our staff survey results put NUH in
the top 25% for: job satisfaction, motivation at work, feeling
able to contribute to improvements and feeling satisfied with
the quality of patient care. These features were recognised by
the CQC during their inspection.
NUH | 2013/14 Quality Account 01
For the second
year running, staff
voted NUH one of
the best trusts in
which to work.
02 NUH | 2013/14 Quality Account
INTRODUCTION
01
While we are proud of our improvements, there are some
areas in which we have not made sufficient progress.
We cover these areas in this Report, and describe our
improvement plans. Notably, we did not achieve the four
hour access target (95%) for emergency patients, despite
much hard work from teams across NUH and investment
in extra beds and staffing. The cumulative effect of more
older and sicker patients being admitted to our hospital and
unpredictable surges in demand on our emergency services
put our services under extreme pressure in our busiest
months of the year. We are giving very close attention to
improving our internal processes to improve the timeliness
and safety of emergency care. We are also working closely
with our health and social care partners in the wider system
to improve the timeliness of emergency care for patients.
We have introduced a new rapid response team to improve
cleanliness inside and outside our hospitals. However,
patients, visitors and self-inspections tell us we have more
work to do, including tackling smoking and consistently
keeping our hospitals clean and tidy, all the time.
Our priorities in the coming year will be:
•Attitudes: embedding our values and behaviours,
particularly in the recruitment and appraisal processes,
and better involving patients in their care
•Behaviour: better communication between staff and
patients
•Combat harms: giving increased attention to (1) harms
from medicines and equipment, (2) mandatory training
and (3) involving trainee staff in this programme
•Doing more to improve the experience of vulnerable
patients and their carers, notably those with dementia
and extreme frailty
•Environmental improvements
•Fewer waits: in the emergency pathway at admission,
at discharge (medication and transport), for
communication (letters)
DECLARATION OF ACCURACY
I confirm, on behalf of all Executive Directors at NUH, that to
the best of my knowledge the information presented in our
Quality Account is accurate.
Peter Homa
Louise Scull
Chief ExecutiveChair
NUH | 2013/14 Quality Account 03
02
QUALITY REVIEW OF 2013/14
Our quality ‘6 pack’
Last year we launched our quality ‘6 pack,’ our authentic way of describing our quality priorities to our patients and staff.
This is how we did in 2013/14.
A: ATTITUDE & BEHAVIOUR
Attitude +
behaviour
Be:
• On guard
• On stage
• On duty
for your patients’ experience
We aimed for all staff to have attended values and
behaviours training by the end of March 2013: we managed
13,200 of our 14,000 staff.
We have embedded our values into our appraisal and
recruitment processes by introducing behavioural-based
questions and involving more patient representatives on
interview panels.
We evaluated the effectiveness of ‘nurse rounding’ (‘Caring
around the Clock’) on patient experience following its
introduction on our inpatient wards in 2012/13. Over
1,000 clinical staff contributed their views on its impact of
ward-level safety and patient experience. We are working
to improve consistency of practice and to build trust and
confidence in our patients through regular contact and
conversations with patients and relatives.
04 NUH | 2013/14 Quality Account
QUALITY REVIEW OF 2013/14
02
“Throughout any treatment, referral, tests,
and information-giving appointments, I have
been treated with the utmost respect and
spoken to as an individual.”
Patient
“I couldn’t imagine having a tube down
my throat and every waking moment
worrying about it. But when I met the
nurse who was with me throughout
the procedure, she guided me through
everything, reassured me and stayed
with me all the time.”
Patient
NUH | 2013/14 Quality Account 05
B: BETTER COMMUNICATION
AND LISTENING
C: COMBAT INFECTION, FALLS AND
OTHER HARMS
Better communication
+ listening
Combat infection +
falls (and other harms)
Involve patients in:
•Risk assess, then act on results
•Use the available toolkits
• Decisions about their care
• Planning our services
Working in collaboration with our community partners, we
undertake comprehensive geriatric assessments on all of our
frail older patients who are admitted as emergencies. Patients
are screened and assessed to ensure they are cared for in
the most appropriate place and have appropriate ongoing
management plans and case managers.
We have achieved high feedback rates in the ‘friends and
family’ test. The information helps make rapid improvements
at ward level. These have included:
•A dedicated room on our Major Trauma Unit for clinicians
to have confidential discussions with patients and relatives
•The development of a new leaflet ‘Welcome to C31’
(an emergency admission unit)
•Our short-stay emergency admissions unit at QMC now
offer every patient earplugs on the evening drug round
and waste-bins are now ‘quiet-closing’
•Refurbishment of a bathroom in Maternity Services
Our national target was fewer than 74 cases of Clostridium
difficile (C diff). We had 90 cases, which is our lowest
number on record. We have had no cases of cross-infection,
no outbreaks since April 2013 and no C diff-related deaths
in 2013/14. No C diff cases this year have been caused by
deficiencies in our care.
The national target for all acute hospitals was zero
MRSA bacteraemias. We had two cases. This compares
favourably with many similar hospitals and has been our
best performance to date. We continue work to prevent
bacteraemia (blood stream infection) including by MRSA.
We have an extensive programme of screening and
decolonisation. The Infection Prevention and Control Team
visit every newly-diagnosed MRSA positive patient, and
those readmitted with MRSA, to ensure patients are offered
support and correct information regarding their diagnosis,
and that we do all we can to prevent serious infection.
Trust estimated C diff & MRSA rates April-March 2014
Estimated MRSA rate per 100,000 bed days
This year we rolled-out our new nurse handover project to
all wards. This improves patient safety with fewer drugs not
given and better completion of fluid balance and observation
charts. The next phase of this work will see the development
of an electronic handover system.
3.0
2.5
2.0
Peer trust 2013/14
1.5
NUH 2013/14
1.0
National average 2012/13
0.5
NUH 2012/13
0.0
0.0
0.5
1.0
1.5
2.0
2.5
Estimated C diff rate per 10,000 bed days
My consultant @nottmhospitals was
amazing yesterday. He listened and
treated me as an individual.”
Patient
06 NUH | 2013/14 Quality Account
3.0
QUALITY REVIEW OF 2013/14
02
CASE STUDY
HOW WARD C53 AT QMC REDUCED FALLS
BY 40% IN 2013/14
In 2013/14 C53 (an acute medical ward) reduced
falls by 40% (from 139 to 84). The staff focused
on consistent assessment for falls risk and actions
prompted by the assessment. We check things that
make falls more likely (eg poor sight, delirium, drugs
or inappropriate footwear) and remove or reduce
as many hazards as we can. Debbi Hughes, Falls
Champion for the ward, said “a number of other
measures have also helped, including minimising clutter
in the ward, installing lamps for use at night, increased
dementia training for staff, and introducing falls and
dementia icons on the patient board so that staff could
easily see who might be at risk”.
We risk assessed 94.98% of patients for venous
thrombo-embolism (blood clots) in line with the
national (96%) and peer hospitals performance.
We have established robust identification of all cases
of hospital-acquired thrombosis. In 2013/14 there were
97 hospital-acquired thrombosis events. Themes from
root cause analyses (RCAs) are shown in the chart on
page 8 and inform our improvement actions.
Falls
We set ourselves a target of 5% fewer falls than in 2012/13.
We achieved a 14.6 % reduction. We had 11.5% fewer
harmful falls (vs our 10% target reduction). We had 9.3%
fewer repeat fallers (short of our 15% target).
Key actions to reduce falls (notably harmful falls) included:
•Our Falls Prevention Team, who provide extra support to
our acute medical wards. Since the team has been in place
we have seen 16% fewer falls. In 2014/15 we will expand
the team into other clinical areas
•Nursing high-falls-risk patients in the same bay to facilitate
their continuous observation
•Learning from previous falls by root cause analysis, notably
focusing our attention on supervising patients during
toileting (while respecting privacy and dignity)
NUH | 2013/14 Quality Account 07
VTE hospital-acquired thrombosis themes
(April 2013 to March 2014) from RCAs
We launched our ‘React to red’ campaign, which is
encouraging staff to identify early skin damage and to ensure
the right plan of care is in place. We have rolled-out new
patient bedside chairs and pressure-relieving boots to protect
patients from pressure damage.
Patient lower limb fracture
Extended prophylaxis prescribed % VTE not prevented
This campaign and the new SSKIN bundle helped us achieve
a 17% reduction in stage three and four avoidable pressure
ulcers (68 compared to 82 in 2012/13).
Extensive patient co-morbidities
Delay to initiation of prophylaxis
Stage four are the most serious ulcers with extreme skin
damage. It is now 12 months since we reported a Stage
four pressure ulcer.
TED stockings not applied/prescribed correctly
Doses of LMWH not reviewed following change in patients condition
Missed prophylaxis doses/not administered
Recognise and Rescue
Prophylaxis prescribed & VTE not prevented
0
1
2
3
4
5
6
7
We have a Trust-wide programme to recognise patient
deterioration and to reduce delays to intervention. We call
this ‘Recognise and Rescue.’ Following this year’s introduction
of a ‘Recognise and Rescue’ dashboard we have seen:
8
No. of
Pressure ulcers
•Nursing escalation of Early Warning Score increase by 46%
Our target was to reduce avoidable stage two pressure ulcers
by 40% in 2013/14. Following the launch of the new SSKIN
bundle (and increased awareness and reporting) we have
seen an increase in the number of reported stage one and
two pressure ulcers. (SSKIN: Support surface, skin evaluation,
keeping moving, incontinence and nutrition).
•Compliance with sepsis bundle increase to 86%
•Administration of antibiotics in less than an hour in severe
sepsis increase to 90%
•No unexpected cardiac arrests in the Nottingham Children’s
Hospital since April 2013
•Failure to rescue incident reporting (i.e. identification of
a learning opportunity) increased three-fold
R – Remove the source of pressure
E – Ensure you protect the skin
A – Assess an evalutate the
impact your action has had
C – Communicate with
your team
T – Talk to your
patient
08 NUH | 2013/14 Quality Account
QUALITY REVIEW OF 2013/14
02
CASE STUDY
SEPSIS
Severe sepsis affects patients of all ages, in all
specialties. It is a medical emergency: prompt treatment
makes the difference between survival and death
(mortality is 30-40%). Our nationally-renowned Sepsis
Action Group have used a range of innovative methods
to raise the profile and urgency of severe sepsis
treatment, resulting in demonstrable improvements in
how effectively and quickly we treat patients at high
risk of death. We have seen a significant fall in critical
care mortality.
Compliance with antibiotics in <1hr
90
80
Percent
The table right shows our improvement in giving
antibiotics within the first hour of diagnosis.
100
70
60
50
40
30
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
2010
2006
20
D: DEMENTIA CARE
Dementia
care
•Look beyond the diagnosis to
the experience of your patient
and their carers
We have developed a three-year dementia strategy which
sets out how we will further improve care for patients
with dementia and their carers. The strategy focuses on
five key areas:
1Personalised assessment and care plans
2Education and training of our staff
3Dementia friendly-environments
4Active research
5Involving and supporting carers of patients with dementia
In 2013/14 we:
•Implemented an electronic screening tool to identify
potential undiagnosed dementia in emergency patients
aged over 75. Patients are then referred to appropriate
specialist services. By year-end, over 90% of eligible
patients were being screened on the admission wards,
with 100% onward referral. We are embedding this tool
across all our adult wards during 2014/15.
•Rolled-out learning from our specialist dementia ward
(Ward B47 at QMC) to other healthcare of elderly
people wards
NUH | 2013/14 Quality Account 09
•Trained over 360 frontline nursing staff in advanced
dementia care. A further 600 healthcare assistants
attended a theatre production and participated in
workshops which explored the complexities of caring
for patients with dementia
•Were one of just nine trusts who gained a place on the
Royal College of Nursing Transforming Dementia Care
programme. This year-long programme (to March 2014)
explored how we can better support and develop staff
to improve our care of patients with dementia.
•Were shortlisted in the ‘dementia friendly hospital’
category in the national dementia care awards
•Surveyed carers of patients with dementia. 71% felt
involved in the care and 65% would recommend the
support given by the hospital to their family/ friends
Safeguarding vulnerable patients
We participated in a benchmarking exercise to assess
staff awareness of indicators of abuse, and ability to
assess mental capacity. Wards and clinics were awarded
gold, green, amber or red status. Year-on-year there was
significant improvement. Over 90% of wards achieved
gold or green status in 2013. There was a correlation
between scores and training attendance. CQC inspectors
were content that our staff had an understanding of how
to protect patients from abuse.
E: ENVIRONMENT IMPROVED
Environment
improved
•Know who cleans what
•Keep your area clutter-free
NUH was assessed between April and June 2013 as part of
the new patient-led inspections of hospital environments.
NHS England introduced the new Patient-Led Assessments of
the Care Environment (PLACE) to replace Patient Environment
Action Teams (PEAT) inspections. Teams comprising at least
50% patients scored wards against 150 standards taking
into account the cleanliness, condition, appearance and
maintenance of patient areas, as well as food and hydration
for patients and their privacy and dignity.
Our scores (and the national average):
MEASURE
Cleanliness
94%
86%
96%
Food
91%
86%
85%
Privacy, dignity and
wellbeing
85%
87%
89%
Condition, appearance
and maintenance
85%
76%
89%
Our second PLACE audit was in March 2014. The results
are expected later this year.
In October 2013, in response to feedback from patients
and staff, we invested in a six-strong rapid response
cleaning team to help improve the overall appearance of
our hospitals – inside and out. The teams take rapid action
to remove clutter from main entrance areas, corridors and
lift lobbies. They challenge smokers (and offer advice on
how to give it up).
We improved a number of our wards by creating new
shower/wet room facilities.
My only gripe with @nottmhospitals is that
they don’t enforce no smoking – hate taking
our son out the main door after clinic.”
Patient
10 NUH | 2013/14 Quality Account
CITY QMC NATIONAL
AVERAGE
QUALITY REVIEW OF 2013/14
F: FEWER CANCELLED OPERATIONS
Fewer cancelled
operations
•Help avoid unnecessary
delays, waits and interruptions
by better organising your work
02
Directorate performance management
Each month our directorates are held to account for
their performance against the Trust’s agreed quality and
performance targets and compliance with expected
standards for each of their clinical services.
Co-producing our quality priorities with our patients
and local community
Our quality improvement priorities are based on feedback
from our patients, carers and staff, and on national
standards. We have engaged and worked with our
patients, public and carers from the communities we
serve through a range of meetings and events, including:
Our 2013/14 rate of on-the-day cancelled operations is our
lowest ever: less than 0.8%. Our total cancelled operation
rate was also lower than previous years. We remain the only
Trust in the country to publish total (‘on the day’ and ‘prior
to the day) cancellation rates.
We committed to zero tolerance of repeat cancellations
and have significantly reduced them to a total of eight in
the year. We will continue with our zero tolerance approach
in 2014/15.
PRIORITIES FOR IMPROVEMENT & BOARD
STATEMENTS OF ASSURANCE
Review of services in 2013/14
•NUH Children and Young People Group
•NUH Equality and Diversity Steering Group
•NUH Sensory Impaired
•NUH Patient Partnership Group
•NUH Directorate patient (and carer) groups
•Healthwatch (Nottingham City and
Nottinghamshire County)
•QMC Residents’ Forum
•Caribbean Carnival
•PRIDE
•Learning Disability Big Health Days
During 2013/14 NUH provided 130 NHS services as identified
in Schedule two, part four of the contract between the
trust and our principal commissioners NHS Nottingham
West Clinical Commissioning Group. The income generated
represented more than 90% of the total income generated
from the provision of NHS services by NUH for 2013/14.
Review of clinical strategies
Over the past 24 months, NUH has reviewed all the data
available to us on the quality of care in 43 clinical service
strategies which covers over 90% of the 130 commissioned
services at NUH. Our review included how each met current
and future care quality standards. In refreshing their clinical
service strategies, services were analysed against national
benchmarks (on mortality, length of stay, readmission rates,
waiting times, patient and staff experience scores, staff
vacancy and sickness rates).
We have carefully analysed the patient feedback we collect
throughout the year – including from surveys, ‘friends and
family’ test, complaints, social media and online feedback
– to identify areas where patients say they wish to see the
biggest improvements. A questionnaire tested this analysis.
We surveyed our public members in summer 2013 and held
a focus group. We surveyed our patients monthly to find out
if they felt safe in our care.
We held 857 patient involvement events across NUH with
15,890 participants during 2013/14. 43 public members
contributed to our online survey on our 2014/15 priorities
and objectives. 20 members attended our focus group
to develop these priorities further. 60 patients, staff and
members responded to our online survey which asked
patients and carers for their views on what our quality
and safety priorities should be in 2014/15.
The result is in our updated quality ‘6 pack’ (priorities)
for 2014/15. There are three key priorities – involving
patients and carers in care, reducing noise at night and
improving discharge.
NUH | 2013/14 Quality Account 11
03
QUALITY PRIORITIES FOR 2014/15
A
C
E
12 NUH | 2013/14 Quality Account
ATTITUDE
• I am always aware of the
impression I give
• We only recruit colleagues
whio share our values
COMBAT HARMS
• I attend mandatory training
• We protect patients from
harm from medications,
infections, falls, pressure
ulcers, blood clots and poor
hydration and nutrition
ENVIRONMENT
• I do my best to keep wards
quiet at night
• We do our best to keep our
workplaces clean and tidy
QUALITY PRIORITIES FOR 2014/15
B
D
F
03
BEHAVIOUR
• I communicate promptly and
clearly to keep patients safe
and well-informed
• We support patients, relatives,
carers and each other
DECREASE DISTRESS
• I use ‘About Me’ to know my
patients
• We adapt our practices to
meet the needs of distressed,
vunerable or frail patients of
all ages
FEWER WAITS
• I prioritise ‘live a day’ actions
for flow
• We act quickly to avoid delays
to patient’s drugs, tests,
treatment and transport
NUH | 2013/14 Quality Account 13
Behaviour: better communication by staff and patients
(recognise & rescue and handover projects). We will:
PRIORITY 1
A
ATTITUDE
• I am always aware of the
impression I give
• We only recruit colleagues
whio share our values
Attitudes: embedding our values and behaviours,
particularly in the recruitment and appraisal processes,
and in better involving patients in their care.
•Our new appraisal system has as a mandatory objective
for staff to demonstrate achievement of all NUH values
and behaviours
In 2014/15 we will
•(1) Complete a values-based audit (seeking the views of
patients, staff and external stakeholders) to inform the
next stage of the development of our ‘culture’
•Ward teams will implement three key actions for carers
(1) record their details in patient records, (2) ‘About me’
documentation will be completed with patients and
carers on admission and includes information about
family life, history, likes and dislikes, current routine, and
usual response to stress or pain, and (3) all carers will
receive trust information on ‘Caring for Carers’
•We will ensure staff are supported to better recognise
patients whose condition deteriorates and escalate and
handover to more senior staff compared to 2012/13
(notably in our admission areas)
•Roll-out an electronic nursing handover which also
captures patient acuity daily
PRIORITY 3
C
•(2) We will roll-out a staff-version of the ‘friends and
family’ test
COMBAT HARMS
• I attend mandatory training
• We protect patients from
harm from medications,
infections, falls, pressure
ulcers, blood clots and poor
hydration and nutrition
PRIORITY 2
B
BEHAVIOUR
• I communicate promptly and
clearly to keep patients safe
and well-informed
• We support patients, relatives,
carers and each other
14 NUH | 2013/14 Quality Account
Combat harms: (1) prevent harms from medicines, (2)
improve uptake of mandatory training and (3) involve
trainee staff in our safety programme.
We will:
•Implement a new approach to mandatory training from
May 2014, which will incorporate a new all staff video
for core training and local training for high risk topic
areas (e.g. including fire and resuscitation training)
•Develop a tool to track harm in medicines and
the impact of safety actions (especially in high risk
medicines e.g. insulin)
QUALITY PRIORITIES FOR 2014/15
PRIORITY 4
D
PRIORITY 6
DECREASE DISTRESS
• I use ‘About Me’ to know my
patients
• We adapt our practices to
meet the needs of distressed,
vunerable or frail patients of
all ages
F
FEWER WAITS
• I prioritise ‘live a day’ actions
for flow
• We act quickly to avoid delays
to patient’s drugs, tests,
treatment and transport
Improve the experience of vulnerable patients
and their carers, notably those with dementia and
extreme frailty by:
Fewer waits: in the emergency pathway at
admission, at discharge (medication and transport), for
communication (letters) and for parking. We will
•Transferring learning from our nationally-recognised
‘dementia ward’ to all healthcare of the elderly wards
•(1) Reduce delays to discharges due to medication and
transport delays
•Ensure we screen all emergency inpatients over the age
of 75 for dementia and referring to the most appropriate
services as promptly as possible
•(2) Reduce wait time for patient letters
PRIORITY 5
E
03
ENVIRONMENT
We will monitor and report progress against each of these
priorities to Trust Board and in performance meetings with
our commissioners. Our ‘Better for You’ programme will
also focus on
•Re-designing outpatient services
•Reducing readmissions
• I do my best to keep wards
quiet at night
• We do our best to keep our
workplaces clean and tidy
Environmental improvements, including:
•(1) Ward focus on reducing noise at night from both
staff and other patients by delivering on individual ward
pledges and updating patient information about the use
of mobile phones
•(2) Working with our staff, partners, local residents and
Carillion, our new provider of Estates and Facilities services,
we will (1) reduce smoking outside our hospitals, (2)
improve responsiveness when areas are not clean and
uncluttered
•(3) Implement the improvements recommended in the
2014 PLACE audit
I waited a long time for an appointment
which was booked over the telephone.
I telephoned to confirm the details two
days prior to the appointment as I had
not received a letter only to be told that
my appointment had been changed and I
had missed it. At no point have I received
any correspondence via mail from the
hospital regarding the appointment, I
now have to wait another two months
which is unacceptable. Surely the booking
department could have contacted me by
phone as they did in the first instance.”
Patient
NUH | 2013/14 Quality Account 15
COMMISSIONING FOR QUALITY AND
INNOVATION (CQUIN) GOALS AGREED
WITH COMMISSIONERS FOR 2014/15
Delivery: Assurance
There are regular CQUIN performance meetings with
commissioners to assess progress and from 2014/15
is included within our ‘Better for You’ whole hospital
programme management governance framework.
The Trust Board receives quarterly reports.
CQUIN goals agreed with commissioners for 2014/15
Nationally-determined
1‘Friends and family test’ (FFT): to include staff FFT, and
roll-out to outpatient settings by October 2014
2Safety Thermometer: focus on further reducing
pressure ulcers
3Dementia screening, clinical leadership and supporting
carers: for 90% of patients aged 75 years and over
admitted as an emergency
Locally-agreed
1Scope the number of patients attending outpatients and
who are admitted to hospital who have fallen within the
last 12 months
2Improve patient experience by improved complaints
management
3Reduce delays in the management of high risk patients
undergoing emergency surgery
4Improve the care of patients who deteriorate whilst in
hospital
5Improve patient safety in transfers of care from and to
hospital
6Information sharing: cross-organisational shared protocols
and information sharing agreements
16 NUH | 2013/14 Quality Account
Specialised CQUINS
1Specialised services quality dashboards. To ensure providers
embed and routinely use the clinical dashboards developed
in 2013/14
2Highly-specialised services to hold a clinical outcome
collaborative audit workshop
3HIV: GP registration and communication. The proportion of
patients diagnosed with HIV registered with and disclosed
to their GP with at least annual communication
4To achieve an increase in percentage of pre-term babies
who receive some of their mother’s milk at final discharge
from neonatal care
5Specialised orthopaedics (Adults) Network Development.
To ensure that complex cases (mainly revisions) are
discussed at network
6Access to prosthetics mutli-disciplinary team (MDT)
assessment. All new referrals to be triaged within four
weeks and offered a MDT within six weeks
7Increase effectiveness of rehabilitation after critical illness.
Implementation of rehab prescription for all patients on
discharge from critical care
Further information on last year’s and this year’s CQUINs
can be found at www.nuh.nhs.uk.
04
ASSURANCE OF SERVICE QUALITY IN 2013/14
04
ASSURANCE OF SERVICE
QUALITY IN 2013/14
NUH was registered with the QCQ
in 2010, and we have continued to
maintain our registration without
conditions or enforcement action
during 2013/14.
CQC INSPECTION IN 2013
The Trust was inspected three times by the CQC during
2013. A responsive review at QMC campus in July 2013,
considered outcome two (consent to care and treatment),
and 13 (staffing), CQC concluded that the Trust had met
outcome two, but had not met standard 13, but that the
impact on patients of this non-compliance was minor.
The CQC undertook a follow-up review of compliance with
outcome 13 in October 2013 and judged that the Trust was
now meeting this standard.
NUH underwent a wave one acute hospital inspection
in November 2013. This was one of the new style Chief
Inspector of Hospitals inspections. The CQC concluded
that our services are safe, caring, effective, responsive and
well-led.
A team of over 60 inspectors, including doctors, nurses and
patients visited our hospitals (planned and unannounced)
in November/December 2013. They examined most of our
services in detail. This included our Emergency Department,
medical, surgical and maternity care, and outpatients. They
inspected our care of children, frail older people and at the
end of life. They assessed our complaints process.
CQC spoke to patients, carers, visitors and staff and to other
organisations, including local commissioners.
NUH | 2013/14 Quality Account 17
As a Trust committed to making continuous
quality improvements, we work hard
to learn from feedback we receive from
patients and partner organisations. We
appreciate we can always do better. The
inspection identified two areas which need
quicker improvement – we were improving
before the inspection, but need to move
faster and more effectively.”
Peter Homa, Chief Executive
The CQC Report said inspectors saw examples of
compassionate care. We found staff to be hard working,
caring and committed. We noted many staff spoke with
passion about their work and were proud of what they did.”
The report describes we have an open culture – staff feel
able to report issues and raise concerns, and we learn from
patient safety incidents.
Many examples of good patient care and excellent work
were identified, including:
•The commitment shown by staff to provide the best
possible patient care
•Our regional trauma centre and critical care units providing
effective care and very good outcomes for patients
•Delivering person-centred care on our dementia wards
•The hand-written letters sent to relatives of deceased
patients by our bereavement nurse on the Lyn Jarrett Unit
(observation and treatment unit) at QMC
•The quality of bereavement care offered by our multifaith centre and compassion shown by staff working in
the mortuary towards relatives and friends of deceased
patients
•Our comprehensive geriatric assessment for frail older
people, which is improving the experience for older
patients in our care
ACTION WE ARE TAKING TO IMPROVE:
1. Attendance at mandatory training
Mandatory training is how staff keep up-to-date in crucial
skills. Despite considerable efforts, fewer than 50% of staff
were up-to-date midway through 2013. Although the CQC
were satisfied there had been no adverse impact on patient
care, the Trust Board had earlier instructed that exceptional
measures be taken to substantially increase training
attendance. There has been considerable improvement since
October 2013, when a new training video was introduced for
all staff (now watched by 11,796 staff). Our target is that all
staff will have watched the film by the end of March 2014.
Some staff require additional specialised training. We aim
to have delivered this training in the highest risk topics by
April 2015. A new approach to mandatory training is being
adopted from May 2014.
2. Medical equipment maintenance
We use several thousand types of medical equipment. We
have struggled to undertake manufacturers’ recommended
maintenance schedules on all items. We have undertaken
a thorough risk assessment to identify priorities for
maintenance, even as we expand the number of machines
and equipment. CQC identified that we had to accelerate
this programme.
Other areas CQC suggest we could make improvements
include:
•Recording use of controlled drugs
•Adopting recognised tool to calculate necessary staff levels
in children’s wards and departments
•Our outpatient service to ensure consistently good
practices
•Visitors’ access to hot meals after 2pm
•Privacy and dignity in the Emergency Department when
the department is busy and under pressure
•The care and range of services at Hayward House at City
Hospital
•Hand gel dispensers should not be empty
•Medical staffing levels and the support given to doctors in
training by senior medical staff
•More patient information in different languages and
formats
•Board governance and leadership
•Ensuring children are given opportunities to give feedback
on their experiences in our care
The Chief Inspector of Hospitals for CQC, Professor Sir Mike
Richards, said:
•Reviewing the time patients wait for outpatient
appointments and ensure people are given information
about waiting times
“Staff we spoke to were positive and engaged and patients
we spoke to were generally positive about the care that they
had received at the hospital. There are improvements that
could be made at the trust to improve the care delivered to
local people, but overall we judge this to be a good trust.”
18 NUH | 2013/14 Quality Account
•Improving outpatient follow-up appointments in
ophthalmology
ASSURANCE OF SERVICE QUALITY IN 2013/14
Our Inspection Report is available to read here on our
website: www.nuh.nhs.uk.
Executive Directors undertake monthly unannounced ward
visits, using the CQC’s framework and standards, to monitor
progress against the essential standards.
PARTICIPATION IN NATIONAL CLINICAL
AUDITS 2013/14
04
which trusts should consider in their 2013/14 Quality
Account. During that period, NUH participated in 92%
(47) of the national clinical audits (NUH is not eligible for
four) and 100% of national confidential enquiries.
The national clinical audits and national confidential
enquiries that NUH was eligible to participate in are
listed in the table below.
During 2013/14 the Department of Health described 51
national clinical audits and six national confidential enquiries
NATIONAL AUDIT 2013/14
Moderate or severe asthma in children (care
provided in Emergency Departments: College
of Emergency Medicine)
Dementia
PARTICIPATION
NUMBER OF
CASES ELIGIBLE/
REQUESTED FOR
SUBMISSION
% OF CASES
SUBMITTED (OR
NO CASES)
Yes
50
100%
No data required
N/A
N/A
Emergency use of oxygen (STEAT)
No
0
Lung cancer
(subscription funded from April 2012)
Yes
450
National Review of Asthma Deaths
No
2
0
Paracetamol overdose (care provided
in Emergency Departments: College of
Emergency Medicine)
Yes
50
100%
No data required
N/A
N/A
Yes
50
100%
Pulmonary hypertension (Pulmonary
Hypertension Audit)
Severe sepsis and septic shock
(College of Emergency Medicine)
National COPD Audit
Inpatient Falls Audit (part of overall FFFAP)
Rheumatoid and early inflammatory arthritis
(new NCAPOP topic under development)
Data collection
ongoing
14
No data required
N/A
N/A
Data collection not
commenced yet
N/A
N/A
Prostate Cancer
(new NCAPOP topic under development)
Yes
1 survey
100%
National comparative audit for use of Anti-D
Yes
131
100%
National Emergency Laparotomy Audit 2013
Yes
approx 96
35%
Inflammatory bowel disease
Includes: Paediatric Inflammatory Bowel
Disease Services
Yes
Biologocal
Therapies Ulcerative
Colitis 50
100%
Oesophago-gastric cancer (NAOGC)
(subscription funded from April 2012)
Yes
>150
100%
Bowel cancer (NBOCAP)
(subscription funded from April 2012)
Yes
432
90%
NUH | 2013/14 Quality Account 19
NATIONAL AUDIT 2013/14
Sentinel Stroke: National Audit Programme
(SSNAP) – programme combines the
following audits, which were previously
listed separately in the Quality Account:
a) Sentinel stroke audit (2010/11, 2012/13)
b) Stroke improvement national audit project
(2011/12, 2012/13)
PARTICIPATION
Yes
NUMBER OF
CASES ELIGIBLE/
REQUESTED FOR
SUBMISSION
% OF CASES
SUBMITTED (OR
NO CASES)
a ) 298
a) 87%
b ) 298
b) 76%
Adult cardiac surgery audit
Yes
Myocardial Ischaemia National Audit Project
(MINAP): formerly Acute coronary syndrome
or Acute myocardial infarction (MINAP)
(subscription funded from April 2012)
Yes
1597
89%
Cardiac arrhythmia: now known as Cardiac
Rhythm Management
Yes
1073
100%
Heart failure
(subscription funded from April 2012)
Yes
406
39%
Congenital heart disease
(Paediatric cardiac surgery)
Yes
33
100%
Coronary angioplasty
(subscription funded from April 2012)
Yes
1321
100%
Diabetes (Adult) ND(A)
Yes
Unknown
4013
National Diabetes Inpatient Audit
Yes
171
96%
National Vascular Registry (elements will
include CIA, National Vascular Database, AAA,
peripheral vascular surgery/VSGBI Vascular
Surgery Database)
Yes
Renal replacement therapy (Renal Registry)
Yes
1217
100%
Renal transplantation (NHSBT UK Transplant
Registry)
Yes
95
100%
No data required
N/A
N/A
Data collection
ongoing
N/A
N/A
Chronic kidney disease in primary care
(new NCAPOP topic under development)
Epilepsy 12 audit (Childhood Epilepsy)
Maternal, infant and newborn programme
(MBRRACE-UK)*
*This programme was previously also listed as Perinatal
Mortality
Data collection
ongoing
Yes
Diabetes (Paediatric) (NPDA)
Yes
Neonatal intensive and special care
No
Paediactric bronchiectasis
(British Thoracic Society)
Paediatric asthma (British Thoracic Society)
20 NUH | 2013/14 Quality Account
62%
100%
340
85%
Yes
6
100%
Yes
21
80%
ASSURANCE OF SERVICE QUALITY IN 2013/14
NATIONAL AUDIT 2013/14
PARTICIPATION
Paediatric intensive care (PICANet)
Yes
Child health programme (CHR-UK)
(also known as the Child Health Clinical
Outcome Review Programme)
No
National Audit of Pregnancy (Diabetes)
Head and neck oncology
(subscription funded from April 2012)
Ophthalmology
(new NCAPOP topic under development)
NUMBER OF
CASES ELIGIBLE/
REQUESTED FOR
SUBMISSION
% OF CASES
SUBMITTED (OR
NO CASES)
343
92%
Yes
Unknown
49
Yes
174
100%
Data collection not
commenced yet
N/A
N/A
National Joint Registry DATE (NJR)
Yes
1731
100%
National hip fracture database
Yes
794
100%
Fracture liaison service
Yes
Unknown
658
Elective surgery (national PROMs programme)
Yes
1489
97%
National audit of seizure management
(NASH)
No
30
0
Adult critical care (case mix programme –
ICNARC CMP)
Yes
2501
100%
Severe trauma (Trauma Audit and Research
Network, TARN): TARN is a Research Database
that is utilised in reporting the Major Trauma
performance and best practice tariff
Yes
1079
100%
National Cardiac Arrest Audit (NCAA)
Yes
134
100%
Data collection has
not commenced
N/A
N/A
Specialist rehabilitation for patients with
highly-complex needs
(new NCAPOP topic under development)
04
*IT data collection issues. Therefore October-December data only available
NUH | 2013/14 Quality Account 21
PARTICIPATION IN NATIONAL CONFIDENTIAL
ENQUIRIES/INQUIRIES 2013/14
During 2013/14 we participated in all relevant enquiries
undertaken by the National Confidential Enquiry into Patient
Outcome and Death (NCEPOD) and by the Maternal Infant
and Newborn Programme (MBRRACE-UK). NCEPOD helps
improve standards by identifying common poor practice.
For the relevant published reports, NUH has identified
a consultant who leads our consideration of the report
and makes recommendations to the Trust’s Clinical
Effectiveness Committee.
TITLE OF STUDY
RETURN RATE* (% OF ELIGIBLE
CASES SUBMITTED BY NUH)
Alcohol related liver diseases
100
Subarachnoid haemorrhage
100
Tracheostomy care
100
Maternal and perinatal mortality surveillance
100
Lower limb amputation
100 – still ongoing
Sepsis study
Study ongoing
*Relates to case notes requested and returned.
In 2013/14, no NUH patients were eligible for the National
Confidential Enquiries (NCI) into Suicide and Homicide by
People with Mental Illnesses (NCI/NCISH).
RESPONSE TO NATIONAL CONFIDENTIAL
ENQUIRIES 2013/14
•Audit of colorectal Enhanced Recovery After Surgery
(ERAS). ERAS success is dependent on both patients and
staff compliance with the multi-faceted ERAS protocol.
The number of patients being discharged by the target
day has more than doubled and the number of patients
succeeding on the colorectal ERAS programme rose from
13.8% in 2012 to 39.3% in 2013
In 2013/14 two National Confidential Enquiries were
published relevant to the services provided by NUH:
Alcohol-related liver diseases – measuring the units
(June 2013) and subarachnoid haemorrhage – managing
the flow (November 2013).
•Radiology reduced the shock frequency in Lithotripsy
(used to shatter kidney stones). The treatment success rate
was improved: total clearance rate (no stone fragments
left after treatment) 53% vs 44%, additional procedures
(21% vs 36%), complication rate (2% vs 10%)
Consultants have been involved in reviewing each Report
and identifying what actions are required to implement
the recommendations at NUH. Both Reports have been
discussed in detail at our Clinical Effectiveness Committee,
a sub-committee of the Quality Assurance Committee.
The Quality Assurance Committee received the following
internal reports (and where necessary action plans) prompted
by external alerts during 2013/14:
LEARNING FROM CLINICAL AUDITS 2013/14
The Clinical Effectiveness Committee receives Reports and
updates from departments across the Trust against relevant
national and local audits.
•Report on coronary atherosclerosis and other heart disease
following CQC alert
•Report on deaths amenable to healthcare prompted by
a Dr Foster alert
•Case note review on deaths coded as dementia/senility
prompted by a Dr Foster alert
During 2013/14 the Clinical Audit Plan consisted 348 audits,
(47 were national audits).
•Retrospective audit following a Dr Foster mortality alert
for diagnosis group pneumonia
Some examples of improvements as a result of audits are:
In each case, NUH analysis and investigation offered
assurance for each alert with no indication of poor
standards of care.
22 NUH | 2013/14 Quality Account
ASSURANCE OF SERVICE QUALITY IN 2013/14
PERFORMANCE AGAINST 2013/14 CQUIN
GOALS AGREED WITH COMMISSIONERS
CQUIN framework 2013/14
04
of NHS services. These goals are known as CQUIN’s
(Commissioning for Quality Improvement and Innovation
payment framework). We had three national, six local, eight
specialised and two community CQUINs in 2013/14, with a
total value of £16,041,737.
2.5% of the NUH’s contract income 2013/14 was conditional
on achieving quality improvement and innovation goals we
agreed with persons and bodies with whom we entered
a contract, agreement or arrangement for the provision
DESCRIPTION OF EACH GENERAL CQUIN
PROGRESS
ACHIEVEMENT/
NON-ACHIEVEMENT
Expansion of ‘friends and family’ test to Emergency
Department (ED) and Maternity Services
Implemented in both the
Emergency Department
and Maternity Services
Achieved
NHS Safety Thermometer: harm-free care. Collection of
Data collection process in
data on pressure ulcers, falls, catheter-associated urinary
place
tract infections, VTE reported monthly
Achieved
Dementia screening for emergency admissions aged 75
years and over to include case finding risk assessment,
investigation and referral to specialist services
System developed and
screening in place
Achieved
Named clinical leadership and appropriate training
for staff
In place
Achieved
Undertake a monthly audit of carers of people with
dementia to test whether they feel supported
Monthly audit in place.
Scores improved
Achieved
Theatre safety: pre-list briefings to 90% compliance,
cultural survey, action plan and implementation
90% compliance
Achieved
Patients perception of safety: monthly survey
In place and results
show improvement in
perceptions
Achieved
Diabetes: reducing the length of stay for patients with
diabetes by one day
Data analysis and review
of national data identified
this was not achievable
Commissioners
agreed to suspend
this element
Reduction in insulin medication errors: 80% error-free
84% error-free
Achieved
Deteriorating patient: increase in proportion of patients
to 60% who receive all elements of the surviving sepsis
resuscitation bundle admitted to intensive care
86% exceeded our target
Achieved
Timely x-ray results to GP: number reported on within
three days 90% by the end of March 2014, and number
reported on within five days 95% by end March 2014
Both targets met
Achieved
Reducing harm by correct use of the early warning
score on patients admitted to acute admission wards
for adults and children
Achieved 4/5 targets
Partially achieved
NUH | 2013/14 Quality Account 23
Specialised and Community CQUINS for 2013/14
DESCRIPTION OF EACH GENERAL CQUIN
PROGRESS
ACHIEVEMENT Q3
Dashboard: to implement the routine use of specialised
services clinical dashboards in the following areas:
radiotherapy, cystic fibrosis and paediatric neurosurgery
Data submitted
Achieved
Adult neurosurgery: to ensure patients receive optimal
outcomes from neurosurgical shunt surgery
Performance report
submitted meeting
compliance against key
indicators
Achieved
Cardiac Surgery: reduce inpatient waits: 71.6% to be treated
within seven days
92.7%
Achieved
Bone Marrow Transplant (BMT): Donor acquisition measures.
This is aimed at gaining a better understanding and
improvement of a number of processes used to identify
unrelated donors. All four elements are equally weighted at
25% of the CQUIN value
Process in place to submit
information on number
of UK donors, tests,
Achieved
searches and turnaround
times
To reduce the cold ischaemic time for all kidney transplants.
This is a two part CQUIN looking at donations after brainstem
death (DBD) and donations after circulatory death (DCD). The
target is 90% transplants to take place with less than 18/12
hours of cold ischaemic time for DBD/DCD transplants
Data presented, including
exceptions. Working
group established to
Achieved
review practice to achieve
target
Neonatal Intensive Care: CONS infections – to achieve a
reduction in the rate of central venous catheter-related
coagulase negative staphylococcus (CONS) bloodstream
infections
Rate-reduction to 11.7%
Achieved
Paediatric Intensive Care: monitoring and minimising the
number of children transferred out of region to a PICU
Data submitted – NUH
service transfers in
patients rather than
transfers to other centres
Achieved
Fetal medicine: 90% of tertiary referrals to be seen within
three days
100%
Achieved
Community CQUINS percentage of 15-25 year olds taking up
offer of Chlamydia screening. A strategic priority is to ensure
Chlamydia screening is promoted to the target age group and
is available in a choice of venues. Uptake needs to increase
in line with the national target together with appropriate
targeting to increase diagnosis of the positive cases. This
scheme is managed jointly by Nottingham City (target 25%)
and County (target 44%) Public Health
Community CQUINS percentage of CASH core service contacts
who are prescribed a Long Acting Reversible Contraception
(LARC) as a % of core service contacts – a strategic priority is
to ensure access to the full range of contraception is available
to all. LARC methods are highly effective and cost effective. As
uptake is lower than required within NHS CASH core services,
an increase in the provision of LARC is a proxy measure
for wider access to the range of contraceptive methods
and should also lead to a reduction in rates of unintended
pregnancy. This scheme is managed jointly by Nottingham
City and County Public Health with a target of 33%
24 NUH | 2013/14 Quality Account
44% city patients
43% county patients
Achieved
34.7% for city patients
33.9% for county
patients
Achieved
ASSURANCE OF SERVICE QUALITY IN 2013/14
WHAT OTHERS SAY ABOUT NUH
Dr Foster Hospital Guide
The Dr Foster Hospital Guide – available at
www.drfosterhealth.co.uk – was published in
November 2013. It is an independent assessment of
standards of care and clinical outcomes. This year
the guide returned to the subject of hospital care at
weekends and looked at a wide range of measures –
mortality rates, readmission rates, access to diagnostic tests
and the length of time that urgent patients wait for surgery.
NUH performed as expected for Hospital Standardised
Mortality Ratio (HSMR) and deaths after surgery and better
than expected on Summary Hospital level Mortality Indicator
(SHMI) (see section on Outcomes Framework).
Our weekend mortality rates for emergency admissions
were identified by Dr Foster as being higher than expected
in 2011/12 in three specialties; trauma and orthopaedics,
cardiology and general surgery.
04
NHS Litigation Authority (NHSLA) risk management
assessment
Previously, organisations were required to be assessed against
a set of risk management standards that had been developed
from key issues identified through claims and incidents.
NHSLA have decided that no further assessments will be
undertaken after March 2014. They are moving the focus
to improving outcomes, learning lessons from claims and
improving patient and staff safety. This new approach is also
designed to reduce duplication of activity carried out by other
external agencies.
NUH has achieved compliance at level one of the Trustwide standards and in March 2014 reached level two of
the maternity standards. We will continue to monitor our
performance against Trust policies which reflect NHSLA
standards through our NHSLA working group.
4Cs
We have worked with Dr. Foster to better understand this
data. The risk of dying is greater for emergency patients
admitted at weekends (compared to weekdays) but when
adjustment is made for the higher age and more severe
illness of weekend admissions (Dr. Foster does not do this),
this mortality is not significantly higher than expected.
2013/14 is the fifth year we have been using the 4C
(complaints, concerns, comments and compliments)
approach to capture feedback from patients, carers and
families. Quarterly reports demonstrating themes from
complaints and examples of learning are received by the
Quality Assurance Committee.
Even with Dr Foster unadjusted data our mortality rates have
reduced from significantly higher than expected to within
the expected range for emergency admissions at weekends
in the most recently available data (April-February 2014). It is
our ambition to roll-out innovation which further improves
outcomes both in week and at weekends.
The charts on page 26 describe the number of complaints
received and the number referred to the Parliamentary Health
Service Ombudsman (PHSO), and the five most common
complaint themes for years 2010/11–2013/14. There are
examples of learning from complaints on pages 27-28.
Since NUH became the region’s major trauma centre in
April 2012, we have had 24-hour consultant cover in our
Emergency Department, increased our emergency theatre
capacity in and out of hours, and doubled the number of
consultant anesthetists present on site during weekdays,
out of hours and over weekends. We also provide a tertiary
specialist cardiology service, admitting the most severely-ill
heart patients.
NUH | 2013/14 Quality Account 25
Number of local complaints and Ombudsman referrals
2010/11
2011/12
2012/13
2013/14
Complaints
737
876
819
693
Ombudsman contacts
67
51
78
*awaiting
response from
PHSO
Ombudsman referrals upheld
against the Trust
2 fully (both
investigations from
2009/10)
2 fully (both
investigations from
2009/10)
1 fully
1 fully
Most frequent complaint themes
2010/11
2011/12
2012/13
2013/14
Standards of care (medical)
Standards of care (medical)
Standards of care (medical)
Standards of care
(medical)
Standards of care (nursing
and midwifery)
Standards of care (nursing
and midwifery)
Manner and attitude
Complications
Manner and attitude
Manner and attitude
Complications
Manner and attitude
Complications
Complications
Communication
Standards of care
(nursing and midwifery)
Communication
Communication (patient
safety)
Discharge
Delays
* Final figures from PHSO not available until June/July 2014
26 NUH | 2013/14 Quality Account
ASSURANCE OF SERVICE QUALITY IN 2013/14
04
Examples of learning and actions from complaints (including case study)
QUALITY OBJECTIVE
AREAS OF CONCERN
ACTION TAKEN
Better communication
and listening
• Plans for care and clinical
intervention not being fully
explained
• ‘Caring around the Clock’ (hourly rounding)
enables patients and relatives to ask questions
about their care and treatment in a timely way
• Lack of communication
leading to increased concerns
of relatives
• Vascular services have developed information
for patients and relatives giving information
regarding when ward rounds occur, and how
to access consultants to ask questions and
receive explanations
• Concerns regarding lack
of information regarding
diagnosis of condition
• Reviews of clinic slots to accommodate
additional follow up slots for patients
requiring explanations and further information
• The outcome and learning from complaints
being shared in multi-disciplinary team
meetings
• The introduction of ‘Accountability around
the Clock’ ensures that information relating to
care and treatment is passed on between staff
members at shift changes
Combat falls
• Relatives unhappy that their
father fell whilst in hospital
• Poor communication relating
to relative’s fall during
hospital stay
• Ward teams have adopted ‘safety briefings’
where patients who are at risk of harm, e.g.
falls are discussed and actions planned to
prevent
• NUH campaign: ‘Act Now….Stop Falls’
adopted in all areas – the focus of our
campaign in 2013/14 was on preventing falls
when toileting and by cohort nursing
• Use of the ‘Falls Toolkit’ – this ensures risk
assessment is completed on patients and the
appropriate plan of care is implemented
• Falls booklet available in all wards explaining
ways to help prevent falls in hospital
Attitude and behaviour
• Patient expressed concern
that the pain he was
experiencing after surgery
was not taken seriously
• ‘’Nurse rounding’ enables the patient to have
regular assessment of pain, and pain killers as
required
• Through ‘nurse rounding,’ Ward Sisters
undertake leadership rounding where they
speak to patients, and also observe how
their team are interacting with patients and
relatives so issues with poor behaviour can be
addressed at the time
NUH | 2013/14 Quality Account 27
CASE STUDY
UNSATISFACTORY END OF LIFE CARE
Background:
The daughter of a lady who was terminally ill was unhappy with the care her mum received and felt we had let her mum
down. She was transferred from QMC to City Hospital in her nightclothes in a cold ambulance. Her mum was then
transferred to two wards which she believed were unsuitable for her mum as she was terminally ill. Her ultimate transfer
to the palliative care ward did not meet her expectations: it was noisy and there was no single room. She felt that her
mum’s final hours were undignified.
Areas of concern:
Actions taken
•Ward staff lacking in the skills to care for the dying
•NUH End of Life Steering Group established in July 2013
to develop the end of life care plan for use in all areas of
the Trust
•Inappropriate transferring of the patient
•Lack of privacy and dignity at end of life
•The Development of the ‘End of Life’ Benchmark has
been developed so that end of life care is now formally
monitored against a set of ‘best practice’ standards in all
in patient areas
•All ward areas have End of Life champions who lead on
the training and development of wards staff in relation
to End of Life care
•A targeted educational initiative has been developed to
support rapid discharge home process for patients who
express a wish to return home for End of Life care
IMPROVING COMPLAINT HANDLING
PATIENT SURVEYS
•2013/14 was the first full year in which we have used the
Patients’ Association Peer Review process. Six complaint
responses a month are scored (poor to excellent) by a panel
of professionals and patient representatives. After early
analysis we are currently piloting a new investigation and
response methodology
We monitor and measure patient experience and satisfaction
in a range of ways, including complaints, national surveys,
local surveys, the friends and family test, social media and
online patient feedback.
•In the Complaint Benchmarking Survey complainants are
surveyed after their complaint is closed. Feedback to date
suggests we often do not fully address complainants’
concerns in our responses. We are now more frequently
offering complainants a meeting (rather than only a letter)
to more fully understand and resolve their concerns
The 2013 inpatient survey results were published in April
2014. Patients were asked 85 questions. This year we scored
significantly better than last year for 12 questions (see chart
opposite):
Learning from complaints is presented via patient stories by
clinical colleagues every month at our Public Board meeting.
These stories are published on our website.
28 NUH | 2013/14 Quality Account
INPATIENT SURVEY (GENERAL)
The survey was carried out on a random sample of patients
who stayed at City Hospital or QMC in July 2013. Of 817
patients asked 392 responded.
ASSURANCE OF SERVICE QUALITY IN 2013/14
04
OUR PATIENT SURVEY RESULTS 2013
OUR
I
SURV NPATIEN
T
E
WAY Y IS ON
E
S
PATIE WE MEA OF THE
N
S
AND T EXPER URE
SATI
I
SFAC ENCE
TION
Resu
.
lts
We did significantly better in 12 key areas
are u from th
s
is sur
feed ed, alon
vey
g
b
sour ack from with
ces, in
othe
Frien
r
cludin
d
comp s and Fa g the
m
laint
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s and ily test,
b
unde ack, to b online
e
r
patie stand wh tter
nts t
hink at
abou
t us..
.
Feedback we receive
from patients
throughout the year
– including these
survey results –
have been used
to inform our
2014/15 quality
priorities
(our quality
‘6 pack’).
Information given about
your condition/treatment in
the Emergency Department
7.9
8.7
Information received
about danger signals to
watch out for on discharge
4.9
5.8
Privacy when being
examined/treated in the
Emergency Department
8.4
9.0
Discussions on equipment
or home adaptations
needed on discharge
7.4
8.5
Waiting time for
a bed or ward
7.4
8.3
Accessibility and
usefulness of
appointment letters
8.5
9.0
Cleanliness of
room or ward
8.5
8.8
Whether patients were
treated with respect
and dignity overall
8.7
9.1
Cleanliness of toilets
and bathrooms
8.0
8.4
Overall experience
7.8
8.1
Emotional support
from staff
6.7
7.4
If patients were asked
to give their views on
the quality of their care
1.5
2.4
We didn’t score significantly worse
in any area in 2013 Vs 2012
Scores are on a scale of 1-10 (10 = best)
MATERNITY SURVEY
Approximately 10,000 babies are born each year in our two
maternity units. The national maternity survey (December
2013) gave us a greater insight into women’s experiences
of these units. 150 women responded (response rate 45%,
similar to the national average). Our scores were in the
‘expected range’ for a trust of our size and for the types
of patients we care for during labour and birth. We can do
better in after-birth care and advice to women about feeding.
We have an action plan to address this. The full reports are
available on our website at: www.nuh.nhs.uk.
‘FRIENDS AND FAMILY’ TEST
Since April 2012, patients leaving our hospitals (on the day
of discharge or within 24 hours) have been invited to give
feedback on their care and experience by answering one
simple question: “how likely is it that you would recommend
this service to a friend or your family?”
In April 2013, along with other NHS trusts across England,
we extended this question to our Emergency Department
patients. We welcomed the introduction of the ‘friends
and family’ test in Maternity in October 2013. Our
inpatient, Emergency Department and maternity results are
continuously improving. We publish our results and how
we compare to our peers every month on our website at
www.nuh.nhs.uk.
ELECTRONIC LOCAL INPATIENT SURVEYS
10,165 inpatients, 5,437 outpatients and 800 carers
completed an electronic survey, providing important
information about their experience in our care and allowing
us to track month-on-month changes.
Between April 2013 and March 2014, 76.1% of inpatients
and 87% of outpatients surveyed felt they were involved
as much as they wanted to be in decisions about their care
and treatment.
65% of carers (non-dementia) and 71% of carers (dementia)
surveyed felt that they had been involved and we had
worked with them as carers.
NUH | 2013/14 Quality Account 29
SOCIAL MEDIA
SUPPORTING CARERS
The Trust receives increasing feedback via social media and
other online feedback forums, including Twitter, Facebook,
Patient Opinion and NHS Choices websites. We have a
system in place to monitor and respond to such feedback
24/7. This feedback is fed into the 4Cs process to give a
rounded picture of patient experience, and is shared with the
relevant ward/clinical area for information and action.
In 2013/14 we:
In 2013/14 NUH had 500 mentions on Twitter, of which
approximately 100 were complaints. Most of these
complaints were about smoking, car parking and waits (on
the phone and waits for appointments).
In the same period NUH received 214 comments from
patients via Patient Opinion and NHS Choices, of which 126
were positive and 73 were negative/complaints. Themes from
this feedback included waiting times and appointments, and
attitude and behaviour.
15 STEPS CHALLENGE
Our ’15 steps’ challenge ward visits are carried out twiceyearly by patients, Board members and clinical colleagues. In
2013we did walkabouts in April and October. They look at
care and the environment through the eyes of patients and
help us to focus on first impressions of our wards (we know
this impacts on patients’ confidence in our care and services).
In 2013/14 the ’15 steps’ visits prompted several changes.
We worked with our patients to standardise ward
performance boards, (including only information that is
relevant to patients and their carers in a format they can
easily understand).
30 NUH | 2013/14 Quality Account
•Developed support and information for carers through
activities and events during carers week
•Reviewed our ‘Caring for Carers’ cards at ‘About Me’
document
•Introduced carers surveys
Over the coming year we will:
•Implement our updated Carers Policy (includes carers
toolkit)
•Continue with monthly carers surveys
ASSURANCE OF SERVICE QUALITY IN 2013/14
04
DATA QUALITY MANAGEMENT AND
ASSURANCE
NHS NUMBER AND GENERAL PRACTICE CODE
VALIDITY
Improving data quality
The Trust submits records to the Secondary Uses Services
(SUS) for inclusion in the Hospital Episodes Statistics. Between
April 2013 and January 2014 the NHS number was included
in 99.7% (99.1% previous year) of admissions and 99.4%
(99.3% previous year) outpatients. Data has not been
included for Emergency Department as difficulties have
been experienced with our local EDIS system and figures are
artificially low. A valid General Medical Practice Code was
included in 100% submissions (as in 2012/13).
Our Data Quality Team has a proactive approach to the
accuracy and completeness of data. The keystone of data is
the patient’s NHS Number. Once this is obtained, the patient’s
identity is verified and all other demographic data items
can be searched in national databases. Our team work with
frontline staff fixing issues where they arise.
Extensive work has been done to enable Emergency
Department Assistants to capture the patient’s NHS Number
when they first present to the department. This has resulted
in improvement in the timeliness and accuracy of our
data capture.
CLINICAL CODING AND ERROR RATE
Clinical coding translates medical terminology written by
clinicians to describe a patient’s diagnosis and treatment into
standard codes. Our data is normally taken from external
audits commissioned by the Audit Commission. This year,
only trusts with the poorest coding rates were audited. NUH
was not subject to the Payment by Results clinical coding
audit during 2013/14 and is one of the strongest performing
trusts (we are in the best 25% of trusts for error rates).
The Data Quality team had an extensive work programme
including cleansing four years of historic data prior to
successfully migrating our huge data store and multiple
systems to a new data collection and storage system (PAS).
Over the next year, our Data Quality team will be taking the
following actions to improve data quality:
INFORMATION GOVERNANCE
•Investigate and, where possible, enable improvement in
the accuracy of other demographic data items (such as the
identity of patients)
•Work with wards and other colleagues to establish
procedures and standards for timeliness in updating
patients’ whereabouts
Information governance guides organisations in handling
all information, in particular the personal and sensitive
information of patients and employees, legally, securely,
and confidentially. The Information Governance Toolkit
allows NHS organisations to self-assess their compliance with
current legislation and national guidance. The Trust’s overall
Toolkit score for 2013/14 was again 80% and graded as ‘not
satisfactory’ (red). The Trust achieved a satisfactory standard
for 44 out of 45 Toolkit requirements. The one deficiency
was a requirement for all staff to complete information
governance training annually. For 2014/15 the Trust has
commissioned a mandatory training film that incorporates
information governance, and has in place a robust plan for
all staff to attend.
Information Governance toolkit self-assessment 2011/12, 2012/13, 2013/14
INFORMATION GOVERNANCE TOOLKIT
PERFORMANCE
2011/12
2012/13
2013/14
Information governance management
66%
73%
80%
Confidentiality and data protection assurance
66%
74%
74%
Information security assurance
80%
84%
84%
Clinical information assurance
80%
86%
80%
Secondary use assurance
79%
83%
83%
Corporate information assurance
66%
66%
66%
Overall percentage
74%
80%
80%
Overall assessment
Not satisfactory
Not satisfactory
Not satisfactory
NUH | 2013/14 Quality Account 31
PERFORMANCE AGAINST NATIONAL QUALITY STANDARDS AND TARGETS IN 2013/14
The table below sets out our performance against a range of quality measures, and provides a comparison with peer hospitals.
QUALITY MEASURE
(%UNLESS SHOWN)
Patients waiting less than 62 days
from urgent referral to treatment for
all cancers
NUH PEERS
2010/11 2011/12 2012/13 2013/14
AVERAGE
13/14
TARGET
14/15
86.8
84.9
82.4
84.9
84.9
84.9
Patients waiting < 31 days from
diagnosis to first treatment for all
cancers
97
96.5
96.3
96.4
97.5
96
Patients waiting < 31 days for
subsequent treatments for all
cancers – surgery
95
94.9
94.5
96.5
96.5
94
Patients waiting < 31 days for
subsequent treatments for all
cancers – drug treatment (%)
99
99.7
99.4
99.8
99.8
98
Patients waiting < 2 months from
referral to treatment for all cancers –
referrals from national screening
programmes
91
91.5
94.2
99
95.8
94
Patients waiting < 2 weeks from
urgent GP referral to date first seen
for all urgent suspected cancer
referrals
94
94.8
93.6
94.7
95.4
93
Patients waiting < 18 weeks from
referral to admitted treatment
93
91
90.5
94.2
89.3
90
Patients waiting < 18 weeks from
referral to non-admitted treatment
98
98.7
98.5
97.5
95.4
95
Patients waiting longer than 4 hours
from arrival to admission, transfer,
discharge
97
93.9
93.9
93.3
94.3
95
7.92
10.15
13.31
3.2
5.3
0
86
83.4
85.1
84.6
86.4
Breaches of the 28 day readmission
guarantee as % of cancelled
operations
Midnight bed occupancy
32 NUH | 2013/14 Quality Account
ASSURANCE OF SERVICE QUALITY IN 2013/14
04
NUH has implemented many of the recommendations of the
Emergency Care Intensive Support Team (ECIST) who visited
in 2012/13. Other significant improvements include:
•12 additional respiratory beds on the Specialist Receiving
Unit and the conversion of an elective orthopaedic ward
to respiratory medicine at City Hospital
•The development of a new and improved emergency
respiratory pathway so that more than 70% of patients
with a respiratory diagnosis are brought straight to the
Respiratory Assessment Unit at City Hospital rather than
transferred from the Emergency Department at QMC
•The embedding of ‘5-a-day’, our five daily actions that
have seen 50% healthcare for older people patients
being discharged before noon and 50% via the Discharge
Lounge. This has aided flow at the start of each day to be
improved, particularly for our most elderly and frail patients
•Significant progress in closing the Acute Medicine
Receiving Unit (AMRU) overnight. This is a unit
which receives patients referred by GP’s for tests and
Consultant Physician review on whether admission to
hospital in-patients beds is required. In 12/13 this unit
frequently stayed open overnight as bed capacity in the
hospital was limited
EMERGENCY ACCESS STANDARD
We did not achieve the 2013/14 national standard for
emergency care of 95% of patients waiting less than four
hours in our Emergency Department (we achieved 93.3%).
In quarters three and four the severity of illness in
admitted patients increased, and there was significant
increase in the number of patients aged over 80 years.
This group of patients usually stay in hospital longer than
average and often require health and social care services
on discharge. The inflow of such patients was quicker than
the outflow – this meant that we could not move patients
as quickly through our hospitals (including through our
Emergency Department.
We had a further ECIST visit in March 2014 to inform our
focus for 2014/15. Our priority is to improve our internal
processes and thereby build greater resilience.
Work will continue into 2014/15 and beyond to embed
improved working practices with provider organisations,
GPs and commissioners to ensure that patients are in hospital
only for as long as required. We will continue to work
as a fully engaged member of the Urgent Care Board to
understand the demands on (and the capacity of) our local
health and social care system.
We are determined to achieve this important safety standard
in 2014/15.
NUH | 2013/14 Quality Account 33
05
QUALITY MANAGEMENT
Our aim is to deliver excellent, caring,
safe and thoughtful healthcare for
patients in Nottinghamshire and the
East Midlands.
Our ambition is to be the best acute teaching trust in
England by 2016 by when each of our services will be in
the top three of our 12 peer hospitals. Our patients will
have healthcare outcomes which achieve or exceed those
described in the NHS Outcomes Framework and NICE
quality standards. We want to achieve this in a way which
is recognisable, measurable and meaningful to everybody
in our community. We are committed to delivering a
compassionate, caring, communicative and collaborative
experience for our patients and their carers.
Two committees meet regularly to ensure we deliver this
strategy. The Quality Assurance Committee (of the Trust
Board) monitors the quality of services we provide and the
quality of our risk management and assurance processes.
34 NUH | 2013/14 Quality Account
The Directors’ Group (Quality) meets monthly. Members are
the executive directors, corporate advisors to the Board, and
our senior clinical leadership team (nurses and doctors). The
group is responsible for leading and delivering the required
quality standards or for driving continuous and sustainable
improvement in the quality of services we provide. Members
are responsible for adopting and sharing local best practice
to enable Trust-wide sharing and learning.
In order to ensure that improving our efficiency and reducing
our overall costs is not to the detriment of the quality of
our services. All cost improvement programmes are risk
assessed using a quality impact assessment (QIA). Each
QIA is reviewed and signed off by the Director of Nursing
and Medical Director and shared with Commissioners
who are able to check and challenge the impact of any
proposed changes before they take place. The Trust’s Quality
Assurance Committee also reviews these on an annual basis.
QUALITY MANAGEMENT
05
Trust Quality Management Structure
TRUST BOARD
BOARD COMMITTEES
Chief Executive Officer
Chief Executive’s Team
Quality Assurance Committee
eight other Committees
Directors’ Group
Four meetings a month, one with a focus on Quality
Investment Governance Committee
Operational Performance Group
Patient and Public Involvement Steering Committee
Theatres Strategy Group
Procurement Steering Group
Equality and Diversity Steering Group
Learning and Education Committee
Sustainable Development group
Clinical Risk Committee
Clinical Effectiveness Committee
Trust Health and Safety committee
Organisational Risk Committee
Pressure Ulcers Operational Group
Infection Control Operational Group
Falls Operational Group
Venous Thromboembolic (VTE) Operational Group
NUH | 2013/14 Quality Account 35
PERFORMANCE AGAINST NHS OUTCOMES
FRAMEWORK
We report our performance against the five domains/areas
of the NHS National Outcomes Framework. We can compare
our performance year-on-year and with other hospitals. We
benchmark ourselves against a group of 12 similar acute
teaching hospitals.
The five domains are:
Domains 1 and 2: Preventing people from dying
prematurely
Hospital Summary Hospital level Mortality Indicator (SHMI)
compares its death rate with the rate in the ‘average’ hospital
(100). SHMI’s much higher than 100 suggest poor care and
those much lower than 100 good care. See table below.
Our latest SHMI is 91. This is within normal range for all
hospitals and for our peer trusts (see table below).
1Preventing people from dying prematurely
2Enhancing quality of life for people with long-term
conditions
3Helping people to recover from episodes of ill health or
following injury
4Ensuring that people have a positive experience of care
5Treating and caring for people in a safe environment and
protecting them from harm
INDICATOR SHMI
NUH
NATIONAL AVERAGE
October 2012 – October 2012 –
September 2013 September 2013
The value and banding
of the summary hospital
level mortality indicator 91 (as expected)
(SHMI) for the Trust
reporting period
100
LOWEST AND HIGHEST
REPORTED TRUST
October 2012 – September 2013
63-118.59
The table below shows how we compare with our peer trusts (data taken from Dr Foster).
Peer group SHMI for all admissions: October 2012-September 2013 (with 95% confidence intervals)
140
Relative risk
120
100
80
60
40
20
Provider
36 NUH | 2013/14 Quality Account
Li
ve
En
rp
gl
oo
an
l
d
av
En
er
ag
gl
an
e
d
hi
gh
En
es
gl
t
an
d
lo
w
es
t
Br
ist
ol
Ro
ya
l
Sh
ef
fie
ld
O
xf
or
So
d
ut
ha
m
pt
on
N
ew
ca
st
le
Ca
m
Bi
br
rm
id
ge
in
gh
am
(U
H
B)
L
an
Ce
ca
nt
sh
ra
ire
lM
ac
nh
es
te
r
Le
ed
s
Le
ice
st
er
N
ot
tin
gh
am
0
QUALITY MANAGEMENT
The Trust Board and Clinical Effectiveness Committee
regularly monitor the SHMI, which provides an important
independent confirmation for our patients and community
that the care provided by our many thousands of staff is safe
and of a high standard.
NUH considers this data is an authentic description of our
mortality rate. NUH has a programme of safety improvements
to reduce complication and mortality rates which includes
improved recognition of deteriorating patient, falls reduction,
and improved sepsis care (as described above).
The SHMI makes no direct adjustment for the proportion
of patients who are admitted for end of life (palliative) care.
If this proportion is inappropriately high, the SHMI will be
inappropriately low (because more patient deaths will be
counted as expected). For October 2012-September 2013,
16.8% of NUH deaths included palliative care code(s) –
see table below for comparison with other hospitals.
INDICATOR – PALLIATIVE CARE CODING
(DOMAIN 1 AND 2)
NUH
PEERS
NATIONAL
AVERAGE
LOWEST TO
HIGHEST
The percentage of patient deaths with palliative
care coded at either diagnosis or speciality level
16.8
22.5
21.2
0 - 44.9
Domain 3: Helping people to recover from episodes
of ill health or following injury
Indicator 1. Patient Reported Outcome Measures
(PROMS)
PROMs describe the health gains after four operations using
pre and post-operative surveys. NUH participation rates
for hip and knee replacements are good. We undertake
relatively few groin hernia repairs and therefore not included
in 2013/14 case mix adjusted data and no varicose vein
operations.
INDICATOR
PROMS
NUH
2013/14
PEER MEAN
2013/14
NATIONAL
AVERAGE
2013/14
LOWEST AND HIGHEST
REPORTED TRUSTS
2013/14
Hip replacement
surgery
0.447
0.412
0.439
0.301 – 0.527
Knee replacement
surgery
0.344
0.321
0.33
0.193 – 0.416
NUH compared to peer trusts (below)
PROMS
0.6
Average health gain
NUH believes that this data is an accurate reflection of
outcomes based on the detailed work undertaken within
the speciality based on previous year’s results. NUH
PROMs for both hip and knee replacement surgery have
improved each year over the last three years (as illustrated
below). The reported patient benefits are slightly higher
than large peer trusts. Compared to the national average
the outcomes are in line with expected. Considering the
complex nature of the work undertaken at NUH these
results are encouraging. The data is kept under review
by the Orthopaedic Board and presented annually at the
Trust’s Clinical Effectiveness Committee.
05
0.5
0.4
0.3
0.2
0.1
0
-0.1
FY
FY
FY
FY
FY
FY
FY
FY
FY
2011/12 2012/13 2013/14 2011/12 2012/13 2013/14 2011/12 2012/13 2013/14
PROMS groin hernia
Min
Max
PROMS hip replacement
National mean
Peer mean
PROMS knee replacement
NUH
NUH | 2013/14 Quality Account 37
Indicator 2. Readmission within 28 days
Our readmission rate for patients 15 years and over is higher than the national average (below).
INDICATOR EMERGENCY
READMISSIONS TO HOSPITAL
2012/13
NUH
PEER
MEAN
NHS
ENGLAND
AVERAGE
LOWEST
REPORTED
TRUST
HIGHEST
REPORTED
TRUST
The percentage of patients aged 0 to 14
readmitted to a hospital which forms
part of the Trust within 28 days of being
discharged during the reporting period
8.1
9.03
10.01
3.75
14.94
The percentage of patients aged 15 or
over readmitted to a hospital which forms
part of the Trust within 28 days of being
discharged during the reporting period
12.54
11.79
11.45
3.35
41.65
The proportion of readmissions is not fully understood.
Whilst readmissions have been subject to audit previously,
we will now undertake clinical reviews during a patient’s
readmitted hospital stay to understand in a patient-centred
way the underlying reasons for the readmission. These
clinical reviews will be undertaken by staff from across the
local health and social care system. A better understanding
of the contributory factors to a patient returning
unnecessarily to hospital will enable us to work with our
community-based partners to design effective interventions
and pathway changes to reduce the number of avoidable
emergency readmissions.
This will enable improvement work across NUH and the wider
health and social care system to:
In 2013/14, the new patient administration system enabled
the development of live and accurate readmissions data.
Patients can be identified during their current hospital
stay (previously patients could only be identified reliably
retrospectively).
Where data and clinical experience show opportunities for
readmission reduction, we will develop and implement short
and medium term programmes of work.
•Live view of current readmissions available to clinicians
•Data can be very rapidly analysed for trends and patterns
38 NUH | 2013/14 Quality Account
1Reduce differences in how readmissions are defined and
measured by different stakeholders
2Help understand why readmissions occur (clinical and nonclinical reasons)
3Help describe the changes needed to improve patient care
and subsequently reduce avoidable readmissions
4Provide best practice in monitoring, reporting and reducing
readmissions.
QUALITY MANAGEMENT
05
Domain 4: Ensuring people have a positive experience of care
Indicator 1: The Trust’s responsiveness to the personal needs of its patients during the reporting period.
NUH 2013/14 compared to the lowest average and highest scores
DOMAIN
LOWEST
HIGHEST
AVERAGE
NUH
NUH IN TOP
20%
Access and waiting
73
96
84.6
88.1
Yes
Safe, high quality
co-ordinated care
53
81
66.1
67.9
No
Better information,
more choice
57
82
68.8
68.6
No
Building closer
relationships
75
93
84.7
85.3
No
Clean, comfortable,
friendly place to be
72
91
80.1
80.3
No
Overall
67
87
76.9
78.0
No
The scores for each question are out of 100. They are the age-gender standardised average score given by patients. A higher
score indicates a better performance, for example a score of 80 reflects an overall result of ‘very good’ and a score of 60
reflect an overall result of ‘good.’ The domain score is the average of the trust scores within that domain. The overall score is
the average of the domain scores.
The Trust believes that this is a true reflection of NUH data. The Trust has taken a range of improvement actions which we
have identified in the patient feedback section above.
Indicator 2: the percentage of staff employed by, or under contract to, the trust during the reporting period who would
recommend the trust as a provider of care to their family or friends.
% staff who would recommend the Trust to a friend or relative
100
%
80
60
40
20
Sh
ef
fie
ld
O
xf
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So
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ha
m
pt
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Ca
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(U
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sh
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lM
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lL
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Br
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an
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N
ot
tin
gh
am
0
Trust
72% of our staff would be happy with the standard of our care if a friend or relative needed treatment. We are in the top
20% of trusts for this indicator
NUH | 2013/14 Quality Account 39
Indicator 3
Le
ed
s
Le
ice
st
er
Sh
ef
fie
ld
O
xf
or
So
d
ut
ha
m
pt
on
N
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Ca
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(U
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L
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t
100
90
80
70
60
50
40
30
20
10
0
N
ot
tin
gh
am
Score
Inpatient (Net Promoter Score)
Trust
Le
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(U
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Trust
The Trust considers both inpatient and Emergency Net Promoter Scores are an authentic representation of our performance
during 2013/14. These scores, including analysis and actions to improve, are regularly discussed at our Patient and Public
Involvement Steering Group. We have seen an increase in both response rate and score across the year.
40 NUH | 2013/14 Quality Account
QUALITY MANAGEMENT
05
Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm
Indicator 1: The percentage of patients admitted to hospital and who were risk assessed for VTE during the reporting
period. NUH averaged 94.78% for VTE assessment. The Trust considers that this data is an authentic representation of our
performance during 13/14. The table below shows our performance against peers and the national average for England.
VTE Assessment as % of Total Admissions
100%
% Assessed
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90%
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Trust
The Trust has (1) ensured the data is available at speciality and consultant level and (2) included this as one of a number of
metrics used to review the quality of care provided by our specialties.
Indicator 2: Rate per 100,000 bed days of cases of C diff infection reported within the trust amongst patients aged two or
over during the reporting period.
Rate of Clostridium difficile infections per 100,000 bed days 2013/14
43
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NUH | 2013/14 Quality Account 41
We have seen a substantial reduction in C diff over the
past five years, we have demonstrated that we now have
a healthcare environment which is near-free from C diff
contamination, and that cross-infection with C diff has been
virtually eliminated. We have wiped out completely the most
common hospital outbreaks strains (ribotypes 027, 001
and 106), and the pattern of C diff infection we now see is
virtually identical to that seen in community onset cases. Our
antibiotic stewardship is of a high standard and continuing
to improve, and we design our antibiotic guidelines around
antibiotics that minimise C diff risks.
In 2013, NHS England started the staged publication
of clinical outcome data for 10 specialties at trust and
consultant level. The specialties are:
Cardiac surgery
•Vascular
•Bariatric
•Interventional cardiology
•Orthopaedics
We aim to reduce C diff infection to an absolute minimum
and we have a highly-active C diff programme at NUH ,
including 2 separate weekly meetings looking in detail at
each case in terms of epidemiology, risk factors, clustering,
antibiotic use, treatment, and overall management. This is
backed up by a comprehensive C Diff action plan.
•Endocrine and thyroid
•Urology
•Head and neck
•Bowel cancer
We have agreed an approach with commissioner colleagues
to measure our performance by focusing on the drivers for
improvement – namely an enhanced root cause analysis
process, a rigorous approach to hand hygiene compliance
and a limit to the number of cases caused by cross infection.
•Upper gastrointestinal (mouth and stomach)
We have included outcomes framework indicator data
for the most recent reporting periods for comparison in
Appendix 3.
This programme is central to our ambition to deliver care
which is free of avoidable harm.
PUBLICATION OF OUTCOME DATA
NUH supports the publication of outcomes of operations
by our surgeons. This information enables patients to make
decisions and helps us provide better services.
42 NUH | 2013/14 Quality Account
This information is published on our website.
TRUST-WIDE PATIENT SAFETY PROGRAMME
SAFER SURGERY
Following a series of serious incidents in theatres in 2010
and 2011 (including 11 never events), we looked hard at
our processes to see how we could improve safety in our
theatres. We developed a three-year strategy with three
inter-related streams: (1) building a safety culture, (2)
understanding and learning, (3) and education and training.
We have not had a theatres-related never event since 2012.
QUALITY MANAGEMENT
05
BUILDING A SAFETY CULTURE
We needed to create an open, responsive culture. We
encouraged ideas and engagement from ‘front-line’ staff.
We created a trust-wide Safe Surgery Group to oversee
our programme of safety work. All incidents with actual or
potential significant harm are reviewed and safety concerns
are raised and challenged.
We have worked hard to understand what our staff think
about safety at NUH. Formal safety climate studies were
completed by over 800 staff in 2012/13 and 2013/14. 80%
of our staff believe safety issues are assigned a high priority,
and that they can influence patient safety.
UNDERSTANDING AND LEARNING FROM
INCIDENTS
We have focused on three areas: improving the process;
individual feedback; and sharing the learning.
A cross-directorate, multi-professional incident subgroup designed a ‘learning from incidents’ staff feedback
tool. There is a cascade of learning using a variety of
methodologies.
We have striven to ensure processes and practices are
consistent in every theatre. Our safety dashboards provide
individual theatre teams with visible, peer-reviewed data on
how they’re doing against local metrics of excellent care.
EDUCATION AND TRAINING
MEDICINES SAFETY
Our medicines optimisation work examines and improves
the way we manage medicines. Focused on patients and
their experiences, the aim is to improve patient outcomes
and prevent avoidable harm. This includes all aspects of
choosing, prescribing, supplying, administering and using
medicines. The Medicines Management Committee (MMC) is
a multi-disciplinary group which works collaboratively using
a patient-centred approach to promote and deliver safety,
effectiveness and value-for-money in medicines use.
We held our third annual Safe Surgery conference: ‘Five Steps
One Shared Goal.’ This year we welcomed 400 delegates
from NUH and our regional partner hospitals.
The MMC regularly reviews relevant policies on how the Trust
procures, handles, stores, prescribes, dispenses, administers
and monitors medication to ensure that this is done as
safely as possible. There is an emphasis on achieving safe
prescribing and improving information flows and patients’
understanding of their medicines, particularly as they transfer
between hospital and community.
Our safety leads developed a training package around the
Five Steps to Safer Surgery that is provided face-to-face and
online. Over 700 staff were trained in 2013. Interaction
with staff in these sessions is crucial to our continual
improvement.
The Drugs and Therapeutics Committee (DTC) ensures that
drugs available for prescription at NUH are appropriately safe,
efficacious and cost-effective. The DTC works closely with the
Area Prescribing Committee when making decisions about
drugs which are also prescribed from primary care.
Each theatre team has a ‘safety champion.’ They attend a
programme around theatre safety, successfully reinforce
key messages (e.g. safety message of the month), and bring
team concerns to wider attention.
Alongside the MMC the Medicines Safety Group (MSG)
works to raise awareness around medicine safety, identifies
medicines hazards, and implements actions to reduce the
likelihood and severity of medicine-related harm. Trust-wide
medication incident data are reviewed quarterly to look for
trends and develop actions. We have prioritised work on
omitted doses by raising awareness of the effect of omitted
or delayed doses and implementing a suite of actions to
ensure our patients receive their medication on time.
We have invested in staff education: theory and practice
of human factors, importance of excellent communication,
learning from ourselves and how good teams work.
NUH | 2013/14 Quality Account 43
The MSG works closely with the Directorates, which
regularly review their medicine-related incidents and
analyse them for patterns and trends according to a
structured algorithm. Twenty reports were received during
2013. The number of incidents reported and investigated,
and the detail of the reports demonstrate an improving
safety culture with respect to medication safety within the
Trust. They have also informed the work plan for 2014/15
when NUH will focus on:
•Improving medicines safety culture, especially among
doctors, when we will focus on improving the visibility
of medicines safety to increase awareness and support
ongoing learning
•Improve the safety of our patients who require insulin
•Procure an electronic prescribing and administration system
HEALTH FOUNDATION SAFER CLINICAL
SYSTEMS PROJECT
The Health Foundation chose NUH as one of eight sites
nationally to pilot a novel approach to improve patient
safety. At the end of a two year project on the Trust’s
busiest admission ward the project’s successes include a
significantly improved safety culture on the ward and better
communication between members of the multidisciplinary
teams to ensure safe medicines management for our
patients. The work has also supported a successful bid for
additional pharmacy staff in admission areas to improve
safety. Primary care colleagues have supported the initiative
by further encouraging patients to bring their medication
to hospital to ensure that the information we hold about
their usual treatment is accurate and there are no delays in
receiving it.
WORKING WITH OTHER ORGANISATIONS
ON MEDICINES SAFETY
NUH has shaped proposed national medicines safety
initiatives including: a tool for assessing the risk of
introduction of new medicines into an organisation and draft
NHS England patient safety alerts on ‘Patient safety alert on
non-luer spinal (intrathecal) devices for chemotherapy’ and
‘improving medication error incident reporting and learning’
the National Medicines Safety Thermometer.
DEPARTMENT OF HEALTH NEVER EVENTS –
MEDICATION RELATED
Ten of the Department of Health’s ‘Never Events’ concern
medication. NUH has developed an assurance framework
which is updated every quarter to allow regular review of
the risks around medication Never Events. This framework
has been adopted by other Trusts in our region to allow
benchmarking of medication Never Events, and shared
44 NUH | 2013/14 Quality Account
learning. In 2013/14, NUH has declared one medication
Never Event. A patient was administered a drug called
methotrexate on two consecutive days rather than
weekly. The patient was not harmed. There has been a
full investigation and an action plan is being implemented.
KNOWING HOW WE ARE DOING
To ensure that medicines management practices are safe
and that changes are indeed improvements, medicationrelated audits are included in the Trust audit plan. Towards
the end of 2012 a Trust-wide audit of omitted doses
was completed and a number of actions have been
implemented during 2013.
CONTINUED LEARNING AND USEFUL
INFORMATION
The Medicines Education Group (MEG) is developing online
learning and assessment modules, has produced a series
of medicines safety podcasts, which have been delivered at
foundation doctor (F1/F2) teaching sessions, has introduced a
new induction programme for trainee doctors and a face-toface “Safe Prescribing” talk (mandatory for all doctors), and
produces a regular newsletter.
HIGH RISK EMERGENCY SURGERY
The Recognise and Rescue programme at NUH aims to
improve our response to the deteriorating patient. Patients
who require emergency surgery are some of the most
vulnerable patients in our hospital. Over the past year, a huge
amount of work has been done by a variety of clinical teams
and individuals from anaesthesia, critical care, radiology and
surgery to improve our emergency surgery service.
‘High risk’ emergency surgery patients account for 20% of
the surgical workload but up to 80% of the mortality and
morbidity. Ensuring these patients get care in a timely and
effective manner is crucial to their experience and outcome.
Building on the success of the Emergency Theatre Case
Review Group, a focussed audit of emergency laparotomies
has delivered great insight into how we can improve.
Over the next two years, we have committed to improve
our management of emergency surgical patients with the
adoption of a High Risk Emergency Surgery CQUIN from
April 2014. The Emergency Laparotomy Group at NUH have
developed a program of care that includes early identification
of high risk patients on admission, fast-track CT scans, and
triggered senior clinical input with rapid admission to theatre
if required. Intra-operative surgical and anaesthetic guidelines
aim to standardise care and ensure patients receive the best
evidence-based care. We hope this high quality care program
will not only improve patient experience and outcome but
also reduce hospital and critical care length of stay and
complication rates.
QUALITY MANAGEMENT
SUPPORTING THE SPEAK OUT SAFELY
CAMPAIGN
TRAINEE DOCTORS (STAFF IMPROVING
PATIENT SAFETY – SIPS)
In 2013, we signed up to the Nursing Times’ ‘speak out
safely’ campaign, demonstrating our commitment to a
culture of openness which includes staff feeling comfortable
to raise concerns about patient safety and quality of care.
SIPS are a new group, formed in 2013, made up of wardbased staff (medical and nursing colleagues) to co-ordinate
patient safety improvement projects across NUH.
We already have an active programme to encourage our staff
to raise concerns. From the Trust Board to each ward and
department, we are committed to ensuring the fundamentals
of patient care are consistently delivered to patients. At
our regular patient safety walkabouts Trust Board member
talk with front line staff who can share concerns directly
with senior colleagues. Our whistleblowing policy protects
colleagues who feel the need for anonymity. At NUH, our
staff can ‘speak out safely.’
Through this campaign we have sought to reassure our
patients, staff and volunteers that we are building a culture
of openness in which staff can raise concerns about care
quality and standards. They can be confident their concerns
will be listened to, taken seriously and acted upon. Following
its inspection of our hospitals at the end of 2013, the CQC
Report described we have an open culture, that staff feel able
to report issues and raise concerns, and that we learn from
patient safety incidents.
05
SIPS is a front-line initiative by all staff and trainees to help
implement our patient safety programme and co-ordinate
projects, communicate with the Trust patient safety leads,
deliver human factors education, and provide a voice for
trainee clinical staff.
PATIENT SAFETY CONVERSATIONS
In 2009, we launched Patient Safety Conversations to enable
front-line staff to talk directly to members of the Trust Board
about their safety concerns. These conversations take place
in the staff workplace and support board members in their
understanding of patient safety issues across the Trust, and
allow triangulation against the level of assurance offered by
other systems and reports.
NUH | 2013/14 Quality Account 45
RESULTS/ACHIEVEMENTS
Incidents reported by degree of harm for acute teaching
organisations (1 April 2013-30 September 2013)
43 patient safety conversations were planned for 2013/14.
41 were completed with 19 at QMC and 22 at City Hospital.
80%
70%
The six most common patient safety issues described by
staff were:
•Patient discharge delays including ‘take-out’ medicines
and ambulance transfers
•Staffing establishment/vacancies and skill-mix
% of incidents occurring
•Estate issues
61.2
60%
50%
40%
30%
•Patient falls
20%
•Equipment availability
10%
•Medication-related incidents
SERIOUS INCIDENTS
Incident reporting is a key element of our patient safety
programme. Our staff appreciate that when we learn
from errors or mishaps we can prevent future harm to our
patients. Recognising and reporting an incident (or near miss)
is the first step to that learning. Our rate of incident reporting
is 10.17 per 100 admissions (NHS England September 2013).
NUH is in the best 25% of acute teaching hospitals for rate
of incident reporting.
Incidents are classified by degree of harm. Those resulting in
severe harm or death undergo serious incident or high level
investigation. Some incidents that have resulted in low or
no harm may still undergo robust investigation due to the
potential for harm.
During the first six months of 2013/14, NUH reported
to NHS England via the National Reporting and Learning
System (NRLS) 6,197 no harm incidents, 3,118 low harm,
792 moderate harm, 15 severe harm and 11 deaths in
patients affected by an incident. This distribution of harms
is similar to that reported in peer hospitals, although NHS
England identifies that organisations apply degree of harm
inconsistently, making comparison difficult (see chart above).
NUH has a robust process in place to review degree of
harm assigned at the time of reporting. This may result in
re-grading the incident to a higher or lower level following
clinical review.
46 NUH | 2013/14 Quality Account
0%
None
Low
Moderate
Severe
Death
Degree of harm
NUH
All acute teaching organisations
There are categories of serious incidents:
1) Never Events
Never Events are a sub-set of serious incidents and are
defined as ‘serious largely preventable patient safety
incidents.’
2) Specific class
The department of health has also classified certain incidents
in specific categories as serious incidents:
•Patient fall resulting in fracture or significant head injury
•Pressure ulcers (stages three and four)
•Specific infection prevention and control incidents
•Maternity related matters for example admission of the
baby or mother to intensive care
3) Unclassified
Such incidents might include medication error or serious
infection causing severe patient harm.
QUALITY MANAGEMENT
05
In 2013/14, we reported 10 unclassified Serious Incidents including two Never Events, as described below:
April 2013 to March 2014
NEVER
EVENT
SERIOUS INCIDENTS (SI) UNCLASSIFIED 2013/14
Transiently retained foreign object following procedure
Wrong site insertion of chest drain
SI
TOTAL
1
1
1
1
Incorrect approach used to insert device prior to surgery
1
1
Wrong level spinal injections
1
1
1
2
Failure to follow-up test results
1
1
Maternity service ICT error
1
1
Patient misidentification
1
1
Tissue process error
1
1
8
10
Medication
1
Total
2
Serious incidents in specific categories – 2013 to 2014
CLASSIFICATION
2012/13
2013/14
Patient falls resulting in a fracture or a significant head injury
49
51
Maternity-related matters
32
39
Infection Prevention and Control
41
28
Pressure Ulcers (stages three & four)
107
104
81
70 - avoidable
26
34 - unavoidable
All our serious incidents are subject to robust investigation,
and the resulting action plan is scrutinised and tracked to
completion by the Clinical Risk Committee.
We have developed bespoke root cause analysis tools for
each of the specific four classes of incident. These ask precise
questions relevant to the type of event.
All our investigation reports are shared with our
commissioners who also apply their level of external
scrutiny. They visit a selection of our clinical areas where
serious incidents have occurred to see first-hand the
improvements made and to gain assurance around our
systems and processes.
NUH | 2013/14 Quality Account 47
COMMUNICATING PATIENT SAFETY
INCIDENTS WITH PATIENTS, THEIR FAMILIES
AND CARERS
The harmful impact of an incident on a patient can
be multifactorial , including emotional and physical
consequences.
We take our responsibility to be honest and transparent
with our patients (duty of candour) very seriously. We are
committed to acknowledging, apologising and explaining
when things go wrong.
When a patient has suffered severe harm or death, the
patient (and/or family/carer) will be given an explanation of
the sequence of events and an apology. They will be invited
to contribute to the investigation and receive a copy of the
investigation report together with an explanation of how the
incident happened and the action being taken as a result.
We share Trust-wide our learning from incidents with all staff
via a safety newsletter to prevent a recurrence.
48 NUH | 2013/14 Quality Account
EXAMPLES OF LEARNING FROM OUR
INCIDENTS
•Improved recognition when a patient’s condition is
deteriorating and clearer defined processes to escalate
concerns to senior staff
•Wider implementation of the World Health Organisation’s
(WHO) surgical safety checklist resulting in bespoke
checklists for areas outside of theatres (e.g: cardiac
catheter labs and radiology) supporting clinicians
preparation for invasive procedures
•Improvements in continuity of senior medical staff cover
on our acute medical admissions wards
•Greater emphasis on ‘safety culture’ including
strengthening of team working and supporting and
encouraging staff to speak up
A copy of our full 2013/14 Annual Patient Safety Report
is available on our website.
06
WORKFORCE & QUALITY
06
WORKFORCE & QUALITY
STAFF ENGAGEMENT
In the 2013 staff survey, NUH was in the best 20% of trusts in the country for overall staff engagement. This is an important
indicator of a safe and effective organisation.
The chart below shows how we did in 2013 compared to 2012.
WHAT YOU THINK OF
WORKING AT NUH
272 staff responded in the 2013 national staff survey
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NUH | 2013/14 Quality Account 49
From May 2014, we will introduce a quarterly ‘friends and
family’ test for staff, covering two questions:
•How likely are you to recommend this organisation to
friends and family if they needed care or treatment?
On a quarterly basis our Director of Nursing and Midwifery
updates the Board on our nurse staffing levels. These reports
are published on our website along with staffing levels by
shift and actual versus planned hours of care on each ward
by month at www.nuh.nhs.uk.
•How likely are you to recommend this organisation to
friends and family as a place to work?”
LEADER AND MANAGER DEVELOPMENT
We will report on these results in next year’s Quality Account.
NUH supports its staff to undertake leadership
development. This year 236 staff attendrd either an
Introduction to Leadership, Building Essential Leadership,
RCN Clinical Leadership programme or Franklin Covey
Performance Improvement course. We have provided over
20 ‘bespoke’ events.
NURSING SKILL-MIX
Our nursing skill mix remains (March 2014) 70% registered
to 30% unregistered nurses. In summer 2013, we began
displaying nurse staffing levels on every inpatient ward
(including establishment against expected staffing levels and
recruitment underway). This information is updated by ward
managers daily. From early 2014 we have published daily
staffing levels for all wards (per shift) on our public website.
50 NUH | 2013/14 Quality Account
07
RESEARCH & INNOVATION AT NUH
07
RESEARCH & INNOVATION AT NUH
Hospitals which engage in research generally provide higher
standards of treatment and better outcomes for patients.
During 2013/14, NUH received £13million of research income
from various National Institute of Health Research (NIHR)
and Research Council funding streams and collaborations
with the Life Sciences Industry. This is a 13% decrease in
income compared to the previous year (£15million 2012/13)
and is mainly attributable to changes in the calculation of
the annual allocations to Trusts by the Treasury and to a
reduction in our patient recruitment to clinical trials rates (and
associated funding).
The number of patients receiving NHS services provided or
subcontracted by NUH in 2013/14 that were recruited during
that period to participate in research approved by a research
ethics committee was as follows: 6,223 patients were
recruited to 406 NIHR adopted studies in 2013/14 (66% of
our target). We are implementing strategic and structural
changes to expand our portfolio of studies, improve
recruitment (and hence increased income).
The Nottingham Health Sciences Biobank (NHSB) collected
more than 18,000 biosamples (a >20% increase in 2013/14).
NUH has become one of the most efficient Trusts in setting
up complex clinical trials. The Trust’s average set-up time is
57 days (against a national benchmark of 70 days). This will
lead to more patients being offered the opportunity to access
innovative healthcare in NUH.
15 new NIHR research grants were awarded to NUH (total
value £7million).
An innovative Research Business Unit has been developed
to provide research management services across NUH.
Our nursing and midwifery research infrastructure leads
on pioneering research into improving compassionate
care. This programme of work will accelerate the
implementation of research findings into service
improvements and staff support.
NUH is proud to host the East Midlands Academic Health
Science Network (AHSN) which provides a unique platform
for the alignment of education, clinical research, informatics,
innovation, training and education and healthcare delivery.
The AHSN goal is to improve patient and population
health outcomes by translating research into practice, and
developing and implementing integrated health care services.
The AHSN will support knowledge exchange networks to
actively share best practice, and provide for rapid evaluation
and early adoption of new innovations.
NUH | 2013/14 Quality Account 51
08
APPENDICES:
APPENDIX 1 –
STATEMENTS OF ASSURANCE
STATEMENT FROM NHS NOTTINGHAM WEST
CLINICAL COMMISSIONING GROUP (CCG)
Clinical Commissioning Groups have in place a collaborative
commissioning arrangement for which Nottingham West
CCG is the co-ordinating commissioner for NUH on behalf of
a number of clinical commissioning groups. We have shared
the Quality Account with a number of the CCGs and this
narrative is a collective response.
The commissioners have in place a number of measures
for monitoring the quality of services we commission.
This includes a schedule of regular visits to all areas of the
hospital. These visits in conjunction with our regular contract
reviews provide commissioners with real time data from
which we can form a judgement about the quality of services
NUH offer.
We are pleased to see the CQC inspection found NUH
to be a safe, effective, responsive, caring and a well lead
organisation in November 2013. NUH have a number of
quality initiatives in place to safeguard the quality of services
delivered to patients and their families. These include a
suite of quality improvement measures (CQUIN) which have
been co-produced with commissioners and bring real added
value. In addition the Trust has a well embedded service
improvement programme; the ‘Better for You’ programme
and good staff engagement.
52 NUH | 2013/14 Quality Account
Commissioners have seen progress in a number of areas
such as; the reduction of never events through the trust
wide safety programme, continued improvement in patient
experience seen through the ‘Friends and Family’ Test and the
Patient Association Peer Review of complaints programme
among others.
NUH do have challenges and therefore risks to quality. These
include financial risks and recruitment of staff. NUH have a
robust assessment of nurse staffing and are compliant with
the Francis recommendations and staffing guidance, however
recruitment of both medical and nursing staff remains a
significant challenge.
In addition the four hour target has remained a significant
challenge for the Trust. It is acknowledged that this is a
system-wide and multi-factorial issue and NUH are engaged
with the healthcare economy to find solutions in order to
improve and meet the target.
Commissioners note the increased number of emergency readmissions and are working with the trust to reduce these.
Dr Guy Mansford, Accountable Officer
NHS Nottingham West Clinical Commissioning Group
APPENDICES
08
STATEMENT FROM THE JOINT NOTTINGHAM
AND NOTTINGHAMSHIRE HEALTH SCRUTINY
COMMITTEE
The Joint Health Scrutiny Committee welcomes the
opportunity to comment on the Nottingham University
Hospitals NHS Trust Quality Account 2013/14. Our comment
focuses on the areas in which we have engaged with the
Trust during 2013/14.
The Committee has found Nottingham University Hospitals
willing to engage, listen and respond positively to
recommendations from scrutiny during the year.
The Committee is pleased to see the sustained improvement
in performance relating to cancelled operations and supports
the Trust’s decision not to continue with this as a specific
priority and instead focus attention on other areas of wait
that are important to patients. The Committee has heard
about work to minimise waits for medication in the discharge
process and feels that there could be scope for better
communicating the discharge process and timescales to
patients so that they have a greater understanding of what
to expect. The Committee has highlighted concerns about
the pharmacy service for outpatients and is pleased that the
Trust has taken this issue on board to explore further.
During the year the Committee reviewed the Trust’s
approach to complaints management and was satisfied that
the organisation has a robust complaints handling process
in place and takes complaints seriously at both an individual
complainant and Trust level.
Over the past few years the Committee has monitored
the ongoing work of Nottingham University Hospitals to
improve care for those with dementia and has welcomed
the improvements that have been made. Committee
members are pleased to hear that the use of ‘About Me’
documentation is being expanded to support other patients
with vulnerabilities and that learning from specialist dementia
care practitioners is being shared with other areas of the
organisation.
During the year the Committee met with clinicians and
‘walked the frail, elderly pathway’ at the Queens Medical
Centre. This visit did not highlight any significant issues of
concern and Committee members felt that patients seen
during the visit were being treated with dignity.
The Committee welcomed the largely positive report arising
from the recent Care Quality Commission inspection of
the Trust and is reassured about the Trust’s governance
arrangements that it was already aware of the issues
before the inspection took place. The Committee has been
assured that recommendations from the inspection are
being implemented, and supports the Trust’s approach of
incorporating this, and work arising from other reviews such
as Francis and Berwick, into ongoing improvement works.
The Committee has heard some concerns about
environmental issues on the Queen’s Medical Centre and
City Hospital sites, which are acknowledged by the Trust in
its Quality Account and it has listened to specific issues that
councillors have raised. The Committee understands the
challenges faced in improving the environment, particularly
at the Queen’s Medical Centre site, and welcomes that this
remains a focus for the Trust going forward. The Committee
will be interested in reviewing progress in environmental
improvements during the forthcoming year.
STATEMENT FROM HEALTHWATCH
NOTTINGHAMSHIRE
Healthwatch Nottinghamshire is pleased to have the
opportunity to read and respond to the Quality Account at
an early stage, although we have not been able to comment
fully, due to the lack of complete data. We note the
openness of the document, which contains comprehensive
data in excess of the requirements.
A huge amount of work is reflected in the document,
demonstrating a range of approaches to improvement.
Some improvements are very clear and are welcomed – for
example the reduction in C diff cases. We particularly like
sections of the document where case studies were used,
such as in the section on complaints. We also welcome the
work with Patient Association, introducing new methods
and sharing stories with the Board and on the website. We
are pleased to see the work which has gone on to improve
dealing with and learning from complaints and will continue
to monitor this.
NUH | 2013/14 Quality Account 53
However, an overall picture of how programmes, priorities,
CQUIN goals, external assessments, national outcomes
framework domains, and various other indicators fit together
is needed. For example – how do these programmes of
action relate to improved outcomes, how are they integrated
at ward level and who is responsible, e.g. at director level for
ensuring goals are met? Perhaps a clear illustration such as
how a patient’s pathway for a specific condition is impacted
on by all the relevant quality initiatives would be useful. This
would help to provide assurance that actions are leading to
improved outcomes and patient experience.
Topics specifically raised with Healthwatch in 2013/14
include: complaints system, discharge, ophthalmology,
hearing services. We have been very pleased with the
response we have received from NUH. For example following
comments received on Ophthalmology Outpatients, we
had an open exchange of information and as a result
Healthwatch are going to be taking part in the SIPPI
(patient) group for Head and Neck Directorate.
We will continue to work with NUH as one of the key
provider Trusts used by the population we represent and
look forward to an increasingly productive partnership in
the future.
STATEMENT FROM HEALTHWATCH
NOTTINGHAM
The organisation’s quality ‘six pack’ is a simple and effective
way of packaging a range of measures being taken in
relation to key priority areas and making them clear for the
benefit of both patients and staff. We are pleased to see the
continuation of this approach into 2014/15.
In relation to these priority areas, of particular note is the
Trust’s work around:
Attitude and behaviour – its programme of ‘rounding’ staff,
embedding core values and behaviours. It is noted that the
staff survey undertaken this year, whilst reflecting the views
of a relatively small proportion of staff, reflects a broadly
positive view of the organisation from amongst its staff and
places it as one of the best NHS organisations to work for.
Better communication – NUH has undertaken some notable
work in this area, particularly in relation to dementia, and
is continuing this work into 2014/15 as it rightly remains a
priority for the organisation.
In its first year of operation, Healthwatch Nottingham
has benefited from NUH’s positive approach to developing
its relationship with the Healthwatch Nottingham Board
and staff.
Fewer cancelled operations – the Trust has made significant
improvements in this area and is now shifting its focus to
delays in emergency care and delayed transfers of care due
to internal waits, both of which remain a challenge and
impact on the patient experience of care.
It is hoped that the dialogue between the organisations will
remain one of openness, with the Trust being proactive in its
engagement with ourselves and neighbouring Healthwatch,
establishing regular meetings to discuss issues of concern and
to update on plans, as well as dealing swiftly and fully with
requests for information.
NUH continues to build the patient experience into its work.
The ‘15 steps challenge’ is a positive element of this. Other
elements of this work are evidenced throughout the Quality
Account and demonstrate a commitment to valuing the
patient and using their views and experiences to improve
the quality of its provision.
NUH has benefited, this year, from an assessment of ‘good’
from the CQC. This very much reflects the majority of
opinion gathered about the Trust through Healthwatch
Nottingham. This is not to say that there have not been
concerns raised by individuals, but these have always been
taken seriously and plans to address specific matters have
been provided as appropriate. It should be noted that the
Trust was commended on its approach to risk management
in its CQC inspection. We are pleased, on the basis of our
experience to date, to be able to support the finding that
the Trust has good systems in place for identifying and
addressing areas requiring improvement.
54 NUH | 2013/14 Quality Account
APPENDICES
08
APPENDIX 2 –
STATEMENTS OF DIRECTORS’ RESPONSIBILITIES
IN RESPECT OF THE QUALITY ACCOUNT
The directors are required under the Health Act 2009,
National Health Service (Quality Accounts) Regulations 2010
and National Health Service (Quality Account) Amendment
Regulation 2011 to prepare Quality Accounts for each
financial year. The Department of Health has issued guidance
on the form and content of annual Quality Accounts (which
incorporate the above legal requirements).
In preparing the Quality Account, directors are required to
take steps to satisfy themselves that:
•the Quality Accounts presents a balanced picture of the
Trust’s performance over the period covered;
•the performance information reported in the Quality
Account is reliable and accurate;
•there are proper internal controls over the collection and
reporting of the measures of performance included in the
Quality Account, and these controls are subject to review
to confirm that they are working effectively in practice;
•the data underpinning the measures of performance
reported in the Quality Account is robust and reliable,
conforms to specified data quality standards and prescribed
definitions, is subject to appropriate scrutiny and review;
and the Quality Account has been prepared in accordance
with Department of Health guidance
The directors confirm to the best of their knowledge and
belief that they have complied with the above requirements
in preparing the Quality Account.
By order of the Board
Chair
6 June 2014
Chief Executive
6 June 2014
NUH | 2013/14 Quality Account 55
APPENDIX 3 –
NHS OUTCOMES FRAMEWORK
PERFORMANCE AGAINST NHS OUTCOMES FRAMEWORK
We report our performance against the five domains/areas of the NHS National Outcomes Framework.
We can compare our performance year-on-year and with other hospitals. The five domains are:
1Preventing people from dying prematurely
2Enhancing quality of life for people with long-term conditions
3Helping people to recover from episodes of ill health or following injury
4Ensuring that people have a positive experience of care
5Treating and caring for people in a safe environment and protecting them from Harm
We have provided information on a number of indicators and shown how outcomes at Nottingham University Hospital
compare to the national average and the best and worst outcomes in the most recent reporting periods for each indicator
in the tables below.
Domain 1 and 2: Preventing people from dying prematurely
NATIONAL
HIGHEST
(WORST)
NATIONAL
LOWEST
(BEST)
INDICATOR
TIME PERIOD
NUH
NATIONAL
AVERAGE
The value and
banding of SHMI
July 2012-June 2013
91.4
100
115.6
62.6
October 2012-September 2013
90.8
100
118.6
63
INDICATOR
TIME PERIOD
NUH
NATIONAL
AVERAGE
NATIONAL
HIGHEST
(WORST)
NATIONAL
LOWEST
(BEST)
% of patient
deaths with
Palliative Care
coded at either
diagnosis or
speciality level
July 2012-June 2013
15.53
20.6
44.1
0
October 2012-September 2013
16.8
21.2
44.9
0
56 NUH | 2013/14 Quality Account
APPENDICES
08
Domain 3: Helping people to recover from episodes of ill health or following injury
NATIONAL
HIGHEST
(WORST)
NATIONAL
LOWEST
(BEST)
INDICATOR
TIME PERIOD
NUH
NATIONAL
AVERAGE
PROMs – hip
replacement
April 2012-March 2013
0.413
0.438
0.539
0.319
April 2013-March 2014
0.447
0.439
0.527
0.301
PROMs – knee surgery
treatment (primary)
April 2012-March 2013
0.307
0.318
0.416
0.209
April 2013-December 2013
0.343
0.330
0.416
0.193
NATIONAL
HIGHEST
(WORST)
NATIONAL
LOWEST
(BEST)
INDICATOR
TIME PERIOD
NUH
NATIONAL
AVERAGE
% of patients aged
0-15 readmitted to
hospital within 28 days
of discharge
2010/11
8.19
4.21
0
16.05
2011/12
8.1
4.19
0
14.94
12.36
6.03
0
22.76
12.54
6.16
% of patients aged 16+ 2010/11
readmitted to hospital
within 28 days of
2011/12
discharge
41.65
Domain 4: Ensuring people have a positive experience of care
INDICATOR
TIME PERIOD
NUH
NATIONAL
AVERAGE
NATIONAL
HIGHEST
(WORST)
NATIONAL
LOWEST
(BEST)
Responsiveness to
personal needs of
patients
2011/12
66.4
67.4
85
56.5
2012/13
67.4
68.1
84.4
57.4
NATIONAL
HIGHEST
(WORST)
NATIONAL
LOWEST
(BEST)
95
25
INDICATOR
TIME PERIOD
NUH
NATIONAL
AVERAGE
Patient Friends and
Family Test score
June 2013
77.8
63
NUH | 2013/14 Quality Account 57
Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm
INDICATOR
TIME PERIOD
NUH
NATIONAL
AVERAGE
NATIONAL
HIGHEST
(WORST)
NATIONAL
LOWEST
(BEST)
% of patients who
were risk assessed
for VTE
Q3 2013/14
94.6
95.8
100
74.1
February 2014
95.6
96
100
77
NATIONAL
HIGHEST
(WORST)
NATIONAL
LOWEST
(BEST)
INDICATOR
TIME PERIOD
NUH
NATIONAL
AVERAGE
Rate per 100,000
bed days of cases of
Clostridium difficile
infection reported
2011/12
23.5
22
0
58.2
2012/13
22.7
17.3
0
30.8
Incidents reported by degree of harm
INCIDENT DEGREE
OF HARM
NONE
LOW
MODERATE
SEVERE
DEATH
Oct 2012 to
31 March 2013
6144
2283
716
29
22
1 April to
31 September 2013
6197
3118
792
15
11
58 NUH | 2013/14 Quality Account
APPENDICES
08
APPENDIX 3 – AUDITORS’ REPORT
INDEPENDENT AUDITORS’ LIMITED
ASSURANCE REPORT TO THE DIRECTORS OF
NOTTINGHAM UNIVERSITY HOSPITALS NHS
TRUST ON THE ANNUAL QUALITY ACCOUNT
In preparing the Quality Account, the Directors are required
to take steps to satisfy themselves that:
We are required by the Audit Commission to perform
an independent assurance engagement in respect of
Nottingham University Hospitals NHS Trust’s Quality Account
for the year ended 31 March 2014 (“the Quality Account”)
and certain performance indicators contained therein as
part of our work under section five (1) (e) of the Audit
Commission Act 1998 (“the Act.”) NHS trusts are required
by section eight 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”).
•The performance information reported in the Quality
Account is reliable and accurate;
Scope and subject matter
The indicators for the year ended 31 March 2014 subject
to limited assurance consist of the following indicators:
•Percentage of patients risk-assessed for venous
thromboembolism (VTE); and
•The Quality Account presents a balanced picture of the
Trust’s performance over the period covered;
•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:
•‘Friends and family’ test – patient element
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).
•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 2013/14 issued by the Audit
Commission on 17 February 2014 (“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
NUH | 2013/14 Quality Account 59
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.
We read the other information contained in the Quality
Account and consider whether it is materially inconsistent
with:
•Board minutes for the period April 2013 to June 2014;
•Papers relating to the Quality Account reported to the
Board over the period April 2013 to June 2014;
•Feedback from the Commissioners;
•Feedback from Local Healthwatch;
•The Trust’s complaints report published under regulation
18 of the Local Authority, Social Services and NHS
Complaints (England) Regulations 2009;
•Feedback from other named stakeholder(s) involved in
the sign off of the Quality Account;
•The latest national patient survey for 2013;
•The latest national staff survey for 2013;
•The Head of Internal Audit’s annual opinion over the Trust’s
control environment for 2013/14;
•The annual governance statement dated 06/06/204; and
•Care Quality Commission quality and risk profiles/intelligent
monitoring dated February 2014 and March 2014
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 Nottingham University Hospitals NHS
Trust in accordance with Part II of the Audit Commission Act
1998 and for no other purpose, as set out in paragraph 45
of the Statement of Responsibilities of Auditors and Audited
Bodies published by the Audit Commission in March 2010.
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 Sandwell and West
Birmingham Hospitals NHS Trust for our work or this report
save where terms are expressly agreed and with out prior
consent in writing.
60 NUH | 2013/14 Quality Account
Assurance work performed
We conducted this limited assurance engagement under the
terms of our appointment under the Audit Commission Act
1998 and in accordance with the Commission’s 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;
•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
responsible 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 measures and can impact comparability.
The prescription 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 precisions thereof, may change over time.
It is important to read the Quality Account in the context
of the criteria set out in the Regulations.
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.
APPENDICES
08
In addition, the scope of our assurance work has not
included governance over quality or non-mandated
indicators which have been determined locally by
Nottingham University Hospitals NHS Trust.
Conclusion
Based on the results of our procedures, nothing has come
to our attention that causes us to believe that, for the year
ended 31 March 2014:
•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
KPMG LLP, Statutory Auditor
Chartered Accountants
St Nicholas House
31 Park Row
Nottingham
NG1 6FQ
26 June 2014
NUH | 2013/14 Quality Account 61
APPENDIX 5 – PEER HOSPITALS
PEER HOSPITALS
Cambridge University Hospitals NHS Foundation Trust
Central Manchester University Hospitals NHS
Foundation Trust
Lancashire Teaching Hospitals NHS Foundation Trust
Leeds Teaching Hospitals NHS Trust
Oxford Radcliffe Hospitals NHS Trust
Royal Liverpool and Broadgreen University Hospitals
NHS Trust
Sheffield Teaching Hospitals NHS Foundation Trust
Southampton University Hospitals NHS Trust
The Newcastle Upon Tyne Hospitals NHS Foundation Trust
University Hospitals Birmingham NHS Foundation Trust
University Hospitals Bristol NHS Foundation Trust
University Hospitals of Leicester NHS Trust
62 NUH | 2013/14 Quality Account
APPENDICES
08
APPENDIX 6 – GLOSSARY OF TERMS
‘15 steps challenge’ – a series of toolkits to help staff,
patients, service users and others to improve patient care.
The improvements should be clear within 15 steps of
entering the area.
Care Quality Commission (CQC) – the independent
regulator of health and social care in England. The CQC
regulates care provided by the NHS, local authorities,
private companies and voluntary organisations.
4Cs – refers to complaints, concerns, comments and
compliments received by NUH.
Carers Policy – NUH’s formal approach to supporting
unpaid carers.
Acute – describes a disease of rapid onset, severe symptoms
and brief duration. The majority of hospital services provided
by QMC and Nottingham City Hospital are for acute illnesses.
Caring around the Clock – the Trust’s version of hourly
rounding day to ensure patients are checked regularly, day
and night.
Area Prescribing Committee – advises CCGs on drug use,
including effectiveness, prescribing, and value.
Case managers – single point of contact, co-ordinating a
case load of patients through treatment (EG in the Regional
Trauma Centre).
Audit Commission – an independent watchdog, driving
economy, efficiency and effectiveness in public services,
including the NHS.
Berwick Report – commissioned in August 2013 to
recommend NHS improvements after the Francis Report on
high mortality rates in Mid Staffordshire.
Better for You – NUH’s continuous improvement
programme acting on ideas from staff and patients.
Biomedical Research Units (BRUs) – partnerships between
NHS Trusts and universities translating basic science research
into practical applications.
Board (of the 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.
CABG – Coronary Artery Bypass Graft surgery. An operation
in which a section of vein or artery is used to bypass a
blockage in a coronary artery, to prevent heart attacks and to
relieve chest pain.
Care pathways – the sequence of health and social care
services a patient in the UK receives after entering the system
during a particular episode of care.
Centre for Maternal and Child Enquiries (CMACE) –
independent charity dedicated to improving the health of
mothers, babies and children through audits and research.
Champions – colleagues who support, lead, and promote
particular causes within the Trust, for instance Falls
Champions.
Chronic Obstructive Pulmonary Disease (COPD) –
a number of lung conditions; including chronic bronchitis
and emphysema.
Clinical audit – measuring the quality of care and services
against agreed standards to indicate areas for improvement.
Clinical coding – clinical coding officers are responsible for
assigning a code for every inpatient stay and day case visit (or
‘episode’). The coding process enables patient information to
be easily sorted for statistical analysis.
Clinical Commissioning Group (CCGs) – replaced
PrimaryCare Trusts with effect from April 1 2013. These
groups will comprise of GPs and other clinicians who will
have a greater influence on how the NHS budget is spent.
There will also be a new national NHS Commissioning
Board to oversee the process.
Clinical dashboard – a clinical dashboard is a toolset
of visual displays developed to provide clinicians with the
relevant and timely information they need to inform daily
decisions that improve quality of patient care.
NUH | 2013/14 Quality Account 63
Clinical Effectiveness Committee – provides assurance
that all NUH clinical services and treatment programmes
meet best-practice standards for assessing and maintaining
their clinical effectiveness.
Clinical variation – the difference between how each
patient responds to the same care.
College of Emergency Medicine – responsible for setting
standards of training and administering examinations in
emergency medicine.
Clostridium difficile (C difficile or C diff) – a healthcare
associated intestinal infection that mostly affects elderly
patients with other underlying diseases.
Commissioners of services – these are organisations
that buy services on behalf of people living in a defined
geographical area. They may purchase services for the
population as a whole, or for individuals who need specific
care, treatment and support. Healthcare services are
commissioned by the local authorities.
Elective – elective care is planned. A patient will be aware
of the required treatment and has been given a date to be
admitted to hospital. Non-elective care is provided in critical
or emergency situations when a medical professional deems
specific treatments or hospital admission cannot be delayed
for more than 24 hours.
Emergency Department (formerly A&E) – specialising
in acute care of patients who present without prior
appointment, either by their own means or by ambulance.
Essence of Care – aims to support localised quality
improvement on wards, by providing a set of established
and refreshed benchmarks supporting front line care across
care settings at a local level. It aims to improve the quality of
fundamental aspects of nursing care.
Early Warning Score – a quick assessment of a patient’s
condition based on blood pressure, heart rate, respiratory
rate, body temperature and level of consciousness.
EDIS – Emergency Department Information System –
ICT system which tracks emergency patients’ status.
Complaint – this is an expression of dissatisfaction that can
relate to any aspect of a person’s care, treatment or support.
It can be expressed orally, through gestures or in writing.
Emergency Theatre Case Review Group – surgeons’
group to review and improve emergency care.
CQUIN – Commissioning for Quality and Innovation –
a process where local NHS commissioners pay trusts for
meeting targets to reward excellence in care.
Equality and Diversity Steering Group – monitors
bullying and harassment cases and their associated outcomes
to advise on improvement.
Cross-infection – cross-infection is the transfer of harmful
microorganisms between people, pieces of equipment, or
within the body, which can cause many complications.
Four hour standard – relates to the emergency access
standard set by the Department of Health. The target
states that at least 95% of patients attending Emergency
Departments must be seen, treated, admitted or discharged
within four hours.
Day surgery – surgery which can be performed in a single
day, without the need to admit the patient for an overnight
stay in hospital.
Department of Health – the Department of Health is the
department of the UK government responsible for policies on
health, social care and the NHS (in England only).
Discharge – the point at which a patient leaves hospital
to return home; or is transferred to another service; or the
provision of a service is formally concluded.
Dr Foster Good Hospital Guide – Dr Foster is an
independent organisation dedicated to making information
about the performance of hospitals and medical staff as
accessible as possible.
East Midlands Academic Health Science Network – a
network of NHS, higher education and industry to identify,
adopt and spread innovative health care across the region.
64 NUH | 2013/14 Quality Account
Francis Inquiry – public inquiry in 2010 into high mortality
rates at Stafford Hospital.
Health Foundation – a charitable health think tank.
Healthcare associated infection – an avoidable
infection that occurs as a result of the healthcare that a
person receives.
Healthwatch – independent patient campaigning and
lobbying group.
Hospital Episode Statistics (HES) – is the national data
for England of the care provided by NHS hospitals and for
the NHS hospital patients treated elsewhere. HES is the data
source for a wide range of healthcare analysis for the NHS,
government and many other individuals and organisations.
APPENDICES
Hospital Standardised Mortality Ratio (HSMR) – is an
indicator of healthcare quality that measures if the death rate
at a hospital is higher or lower than you would expect. The
HSMR compares the expected rate of death in a hospital with
the actual rate of death. Factors such as age and severity of
illness are taken into account.
Medicines optimisation – the safe and effective use of
medicines to enable the best possible outcomes.
Hourly rounding – nurses proactively visiting patients on an
hourly basis, on top of their usual duties. This is the basis of
NUH’s ‘Caring around the Clock’ programme.
MRSA – methicillin-resistant Staphylococcus aureus –
bacteria that can cause infection in a range of tissues such
as wounds, ulcers, abscesses or bloodstream.
Infection Prevention and Control Team – senior multi
disciplinary, cross site infection control specialists.
NCEPOD – National Confidential Enquiry into Patient
Outcome and Death – a charity which uses surveys to
review medical and surgical clinical practice and makes
recommendations.
Information Governance – how organisations handle
information, particularly personal data. In the NHS, personal
information is dealt with legally, securely, efficiently and
effectively in order to deliver the best possible care.
Myocardial Ischaemia National Audit Project (MINAP)
– examines the quality of management of heart attacks
(myocardial infarction) in hospitals in England and Wales.
NCI/NCISH – National Confidential Inquiry into Suicide and
Homicide by People with Mental Illnesses – Manchester
University’s leading research programme into the subject.
Intensive Care National Audit & Research Centre
(ICNARC) – a centre to foster improvements in the
organisation and practice of critical care (intensive and high
dependency care) in the UK.
National Emergency Laparotomy Audit – audit to
improve care for emergency laparotomy patients, following
evidence of high mortality rates.
Intrapartum care – management and delivery of care to
women in labour.
National patient surveys – legally required Trust surveys
of patients, to help set future priorities.
Joint Health Scrutiny Committee (known as Overview
and Scrutiny Committees (OSCs)) – local authority health
service scrutiny committees.
National Institute for Clinical Excellence (NICE) – an
independent organisation responsible for providing national
guidance on promoting good health and treating ill health.
Keogh Review – a review ordered by the prime minister
to review the quality of care and treatment at hospitals with
persistent high mortality indicators, following the Francis
Inquiry.
National Institute for Health Research (NIHR) – is the
body responsible for creating a health research system in
which the NHS supports outstanding individuals, working
in world class facilities, conducting leading edge research
focused on the needs of patients and the public.
Liverpool Care Pathway – an integrated care pathway that
is used at the bedside to drive up sustained quality of the
dying in the last hours and days of life.
Local Involvement Networks (LINks) – individuals and
community groups, such as faith groups and residents’
associations, working together to improve health and social
care services. In Nottingham there are two LINks groups –
one for Nottingham city and another for Nottinghamshire.
MBRRACE-UK – Maternal Infant and Newborn Programme
– online reporting system for stillbirths, perinatal deaths, and
infant deaths.
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National Patient Safety Agency (NPSA) – an arms-length
body of the Department of Health that leads and contribute
to improved, safe patient care by informing, supporting
and influencing organisations and people working in the
health sector.
National Reporting and Learning System (NRLS) –
a central database of patient safety incident reports to
identify hazards, risks and opportunities.
Never Events – a sub-set of Serious Incidents and are
defined as ‘serious largely preventable patient safety
incidents’.
MDT (multi-disciplinary team) – a team of representatives
from several different professional backgrounds who all have
different areas of expertise.
NUH | 2013/14 Quality Account 65
NHS Blood and Transplant (NHSBT) – provides a reliable,
efficient supply of blood, organs and associated services to
the NHS.
NHS Choices – NHS-run health information website.
NHS East Midlands – is the strategic health authority for
the region providing leadership of the NHS across Derbyshire,
Leicestershire and Rutland, Lincolnshire, Northamptonshire
and Nottinghamshire. The role of NHS East Midlands is to
relay and explain national policy, set direction and support
and develop all NHS Trust bodies (Primary Care Trusts and
NHS Trusts providing acute, mental health and ambulance
services).
NHS Foundation Trust – NHS foundation trusts are a type
of NHS trust in England and have 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.
Ombudsman – government body which investigates
complaints of unfairness or poor service about the NHS.
Overview and Scrutiny Committees (OSCs) – see Joint
Health Scrutiny Committee.
Paediatric – medical care of children.
Patient – this is a person who receives health or social care
through a regulated activity. Patients are defined as ‘service
users’ in the Health and Social Care Act 2008.
Patient Environmental Action Team (PEAT) – an annual
assessment of inpatient healthcare sites in England that
have more than 10 beds. It is a benchmarking tool to ensure
improvements are made in the non-clinical aspects of patient
care including environment, food, privacy and dignity. The
assessment results help to highlight areas for improvement
and share best practice across healthcare organisations in
England.
NHS Litigation Authority (NHSLA) – the NHSLA is a
special health authority responsible for handling negligence
claims made against NHS bodies. It also aims to raise safety
standards and reduce the number of negligent or preventable
incidents through its risk management programme. This
incorporates organisational, clinical and health and safety
risks. Most healthcare providers, including NUH, are assessed
against their standards.
Patient and Public Involvement Steering Group –
a directors’ committee overseeing the patient and public
involvement.
NHS Outcomes Framework – sets out the outcomes
and corresponding indicators used to hold NHS England to
account for improvements in health outcomes.
Patient Partnership Group – works with the Patient and
Public Involvement Steering Group to communicate and
engage with patients and public.
NHS Number – is the only National Unique Patient Identifier,
used to help healthcare staff and service providers match you
to your health records.
Patients’ Association Peer Review process – a new
approach to complaints handling which includes establishing
panels to assess the quality of complaints investigations
through regular sampling and peer review, run by the
Patients Association.
NICE – National Institute for Health and Care Excellence
– official body giving independent, authoritative and
evidence-based guidance on the most effective ways to
prevent, diagnose and treat disease and ill health, reducing
inequalities and variation. All NHS treatments must be
approved by NICE.
Nottingham West Clinical Commissioning Group –
12 local GP practices in Eastwood, Kimberley, Stapleford,
Beeston, Bramcote and Chilwell who plan and pay for local
health services.
Nurse handover – information passed from nurses at the
end of one shift to nurses starting the next shift.
66 NUH | 2013/14 Quality Account
Patient Opinion – a website (www.patientopinion.org.
uk) that allows patients and carers to find out what other
people think of local hospitals, hospices and mental health
services.
Perinatal – the period shortly before or after birth.
Peri-operative – the care that is given before, during and
after surgery.
Picker Institute – this is a not-for-profit organisation that
works with patients, professionals and policy makers to
promote a patient-centred approach to care. The Institute
uses surveys, focus groups and other methods to gain a
greater understanding of patients’ needs.
APPENDICES
PROMS – Patient Reported Outcome Measures –
PROMs measures health gain in patients undergoing
hip replacement, knee replacement, varicose vein and
groin hernia surgery in England, based on responses to
questionnaires before and after surgery.
Primary care – first contact and principal point of
continuing care, such as GP or community service.
Providers – organisations that provide NHS services,
such as hospitals and clinics. They may be NHS, private, or
voluntary-run.
Rapid Response Team – a team of Estates and Facilities
staff focussing on swiftly cleaning and tidying areas of NUH.
Research Council – funding and training body for
researchers.
Root Cause Analysis – a method of problem solving that
tries to identify the root causes of faults or problems and
remove them.
Quality ‘6 pack’ – six priorities underlying the Trust’s
quality strategy.
Quality Assurance Committee – a sub-committee of the
Trust Board, which oversees the delivery of the Trust’s quality
and patient safety strategies and monitors improvement.
Quality, Innovation, Productivity and Prevention
(QIPP) programme – Government strategy for saving
£20billion in the NHS budget by 2015 while improving care.
Quality Impact Assessment (QIA) – a structured analysis
of the impact a particular project or action may have on the
Trust’s Quality Strategy.
Patient-Led Assessments of the Care Environment
(PLACE) – a programme of volunteer community teams
assessing patients’ privacy and dignity, food, and cleanliness,
focussing entirely on the care environment rather than
clinical issues.
Patient Led Action Teams (PEAT) inspections – the
predecessor of PLACE.
Person-centred care – care in which patients are supported
to make informed decisions about their own health and care.
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Pulmonary hypertension – is a condition in which high
blood pressure in the arteries of the lungs (the pulmonary
arteries) is abnormally high.
Regional Trauma Centre – NUH hosts the East Midlands
regional trauma centre, with leading experts in trauma and
orthopaedic surgery, neurosurgery and intensive care. It is the
hub of a network which has been set up across the region.
Research – clinical research and clinical trials are an
everyday part of the NHS, and often conducted by medical
professionals who also see patients. 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.
Transforming Dementia Care programme – a major
year-long RCN programme in which nine NHS trusts
developed innovative ways to improve dementia care
in hospitals.
Safeguarding – safeguarding means putting measures in
place to enable people to live free from harm, abuse and
neglect. The measures protect their health, wellbeing and
human rights. Children, and adults in vulnerable situations,
need to be safeguarded.
Safer Surgery Checklist – a tool for the relevant clinical
teams to improve the safety of surgery by reducing deaths
and complications. In June 2008, World Health Organisation
(see WHO) launched a second Global Patient Safety
Challenge, ‘Safe Surgery Saves Lives’, to reduce the number
of surgical deaths across the world. The checklist is part of
this initiative.
Safety culture – staff’s constant and active awareness of
the potential for things to go wrong. Both the staff and the
organisation are able to acknowledge mistakes, learn from
them, and take action to put things right.
Safety dashboard – a single page summary of key safety
statistics, such as infections, pressure ulcers and falls. Safety
Leads – member of staff with particular responsibility for
safe practice.
Safety Thermometer – the NHS’s IT system for its
Safety Dashboard.
Secondary User Services (SUS) – single source of
comprehensive data to enable a range of reporting
and analysis.
NUH | 2013/14 Quality Account 67
Sepsis Action Group – consultant led project to raise
awareness of sepsis as a medical emergency and cut the
number of deaths it causes.
‘We are here for you’ – our values, known as ‘we are here
for you’, developed after consultation with patients and staff,
describe the NUH way of doing things.
Skill-mix – making sure the duty staff collectively bring
the right combination of skills for the work that needs to
be done.
World Health Organisation (WHO) – is the directing
and coordinating authority for health within the United
Nations system. It is responsible for providing leadership on
global health matters, shaping the health research agenda,
setting norms and standards, articulating evidence-based
policy options, providing technical support to countries and
monitoring and assessing health trends.
SSKIN – a five step model for pressure ulcer prevention.
The acronym stands for Support surface, skin evaluation,
keeping moving, incontinence and nutrition bundle.
Stroke Improvement National Audit Programme
(SINAP) – a national audit to assess and improve stroke
care, run by the Stroke Programme at the Royal College of
Physicians (RCP).
Smoking cessation – is the process of discontinuing the
practice of inhaling a smoked substance.
Staff survey – the official annual national survey of NHS
staff by the Care Quality Commission.
Strategic Health Authority – see NHS East Midlands.
Summary Hospital level Mortality Indicator (SHMI) –
the ratio between the actual number of patients who die
following hospitalisation at the trust and the number that
would be expected to die on the basis of average England
figures, given the characteristics of the patients treated there.
Think Glucose campaign – is a major programme from
the NHS Institute, designed to improve the management of
people with diabetes when they are admitted to hospital.
Transfer of Care – the process of discharging a patient from
NUH care to home, a community health service, or social
services
Urgent Care Board – committee of NHS organisations
focussing on improving emergency care provision.
Venous thromboembolism (VTE) – a condition in which a
blood clot (thrombus) forms in the vein.
Vascular Society of Great Britain and Ireland (VSGBI)
– a registered charity founded to relieve sickness and to
preserve, promote & protect the health of the public by
advancing excellence & innovation in vascular health,
through education, audit & research.
Wave one acute hospital inspections – CQC’s
inspection of 18 NHS Trusts in 2013, using a more intensive,
data-analysis driven methodology.
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