University
College
Hospital
National Hospital for Neurology and
Neurosurgery
Eastman
Dental
Hospital
Royal National
Throat, Nose and Ear Hospital
Heart
Hospital
Royal London
Hospital for
Integrated Medicine

28
28
28
32
45
45
45
45
46
35
36
36
42
44
45
4
6
8
54
3
4
4
56
57
59
2
University College London Hospitals NHS Foundation Trust

1
This is reflected in our top 10 objectives and is a constant focus in everything that we do.
This year has been demanding – we have had challenges in achieving the
18 week referral to treatment waiting times targets and the 62 day cancer target.
Through investment and huge commitment from all staff, we have made excellent progress but this remains a challenge for next year. We are very pleased that we have maintained our high standards of quality despite these pressures. For example, we have improved the care of patients with dementia and made good progress on reducing falls with harm and pressure ulcers and have improved ways to share learning from incidents and complaints. Along with most other trusts nationally, we have had difficulty in meeting the operational standard that
95 per cent of our patients are seen in our emergency department within four hours. However in the most challenging winter period we did achieve the 95% target and were the third best performer in
London – a great achievement despite considerable pressures.
These are exciting times as we continue to work on our ‘UCLH Future’ plans, our strategy for the move of cardiac services to Barts Health NHS
Trust and the development of our cancer services.
Pressures will continue next year as we continue to face very high demand for our services but I am confident that we will maintain our unrelenting focus on the three strands of quality: safety, effectiveness
(clinical outcomes) and patient experience.
This quality account contains data on our performance in relation to quality which by its nature is less precise than financial information and there are acceptable differences in the way in which this type of information is measured.
With this in mind UCLH has done its best to ensure that, to my knowledge, the information in the document is accurate
(with the exception of the matters identified in respect of the 18 week referral to treatment incomplete pathway indicator as described in section
5).
Quality Account 2014/2015
3

2
We have been very focused on responding to the significant financial pressures in the NHS. However, this is also an opportunity to improve quality, particularly in patient experience.
We have developed a programme of change –
‘UCLH Future’ – that centres around four key areas:
Care delivery system – about how we deliver care;
iCare – about use of technology and information to improve the patient experience;
UCLH Institute – about learning through improvement; and
Organisational Development – about leadership culture and change.
With these key areas we aim to take UCLH from being one of the best trusts in the NHS to one of the best worldwide.
UCLH consists of University College Hospital, the
Royal National Throat Nose and Ear Hospital, the
Royal London Hospital for Integrated Medicine, the
National Hospital for Neurology and Neurosurgery, the Heart Hospital and the Eastman Dental Hospital.
In July 2014, University College Hospital was noted to be the safest hospital in England after NHS England published new data on nurse staffing levels and systems of patient safety.
The hospital achieved a 114% score in safe staffing levels and was the only hospital in the NHS to perform above expectations in all six categories:
Patient safety reporting
Infection control and cleanliness
Patients assessed for blood clots
NHS England patient safety notices
Care Quality Commission national standards
Recommended by staff
All the other hospitals in UCLH performed excellently.
A number of developments were initiated as a result of the Care Quality Commission’s (CQC) inspection in November 2013. The inspectors said that improvements were needed in relation to the security of patient records on the acute medical
4
University College London Hospitals NHS Foundation Trust wards. We have modernised our casenote storage and the importance of keeping information safe has been extensively communicated and we have included casenote compliance in our Mandatory Training.
Monitoring and assurance is undertaken at our weekly Matrons Quality Rounds (see glossary), and larger multi-professional ‘Improving Care Rounds’ (see glossary). We also have developed a casenote audit app which we use in some areas. These changes show that we continue to demonstrate improvement.
The CQC inspection also identified the need to improve nursing documentation. As a result we have implemented the new SOAPIER (see glossary) documentation tool Trust wide. This provides a consistent patient centred approach to nursing documentation in relation to plans of care, and these are regularly checked for quality of documentation.
To monitor progress, notes are reviewed with the nurse caring for the patient on that shift, they are checked daily by the ward sister, weekly by the matron, fortnightly on the quality rounds and monthly during the unannounced visits by the Chief
Nurse Team.
Ongoing monitoring has shown that whilst great improvements have been made with plans of care, improvements are still required with accurate dating and signing.

Last year we highlighted that we needed to improve our outpatient experience. In response, this year we have run an ambitious outpatient improvement programme with actions focused on patient experience and the movement of patients, involving all our outpatient sites. The most intensive of these programmes was the ‘Productive Outpatient
Programme’ which was run on a much broader scale than in previous years. Since its inception in 2011, 105 clinical teams have participated in the programme.
955 individual clinics have benefited, improving the experience for 258,710 patients per year.
15 per cent to 11 per cent meaning that 736 more patients attended their appointments during the project period. In addition to improving the way specific clinics are run, and thus waiting times for patients, we have also tackled issues which affect the whole site including the waiting area, signage, and queuing for reception. The programme has also enabled patients to be seen by the most appropriate clinician on their day of attendance, reducing the number of journeys patients make to the RNTNEH for their care. Feedback from staff and patients has been extremely positive.
As a result
93 per cent of clinics have improved the ability to see more patients for first consultation sooner (i.e. the time from their referral from the GP to a first appointment has reduced)
64 per cent of clinics have improved patient attendance levels (by reducing the number of patients who do not attend on the day) and can therefore see more patients per clinic
Services seeking to reduce waiting times for either a new or follow up appointment have achieved this with the degree of reduction ranging from 87 per cent to 30 per cent.
Every clinic at the Royal National Throat Nose and Ear
Hospital (RNTNEH) participated in the programme between July 2014 and February 2015. During the programme the number of wasted appointments through patients not attending was reduced from
Staff continue to recommend UCLH as a place to work and to be treated, and our overall staff engagement scores remain in the top 20 per cent of acute hospitals. However, most NHS staff survey results are generally less positive than last year and there were less favourable responses from UCLH staff in respect of working longer hours, work related stress, discrimination and harassment and bullying and abuse by other staff. Work is being undertaken to help the areas that had the most challenging results.
We wish to improve further the use of the WHO safe surgery checklist (see glossary) and associated theatre behaviour and so we have included it as one of our safety priorities for 2015/16 – reducing surgical harm
(see Section 4, Priority 2).
Quality Account 2014/2015
5

Despite the progress we have made (described above) there is still work to be done and this continues to be one of our priorities (see Section 4, Priority 1.2).
The Trust started 2014/15 with long referral to treatment (RTT) waits across a range of specialties and being non-compliant with the three national RTT standards (these are 90 per cent of patients treated via admission and 95 per cent of patients treated in out-patients to be within 18 weeks, and 92 per cent of patients waiting for treatment to be under 18 weeks).
This was due to increasing referrals, with a 30 per cent increase in elective (planned) referrals seen over the last 5 years, in particular in our specialist areas such as neurosurgery. In 2014/15 we made improvements by undertaking more surgery and improving access to diagnostic tests and investigations. We also improved our waiting list management and reporting. We are now achieving
2012/13 2013/14
Improve patient experience in five CQUIN areas.
Improve patient experience CQUIN areas.
two out of the three RTT standards, and plan to be fully compliant from June 2015. For further information on this indicator see section 5 (Access targets and outcome indicators).
We are aware of the impact that waiting to be seen has on patients’ experience and the anxiety this must cause and it is a priority for us to improve our waiting times. To reduce the risk of harm to patients we inform GPs of those who have waited
26 weeks or more, and ask them to inform us of any clinical concerns that might result from delay. For some conditions, it is difficult to assess the extent to which delays have an impact; however, we have not detected any harm to date.
The table below charts our Quality account priorities over the last few years and demonstrates the continuity of some priorities alongside newly emerging priorities.
2014/15
National inpatient survey question- how would you rate your overall experience.
National inpatient survey question – involved in decisions about care and treatment.
National inpatient survey questions – explanation about how you could expect to feel after your operation.
2015/16
National inpatient survey question – how would you rate your overall experience.
National inpatient survey question – Care: more than 5 minutes to answer call button.
National inpatient survey question: Staff contradict each other.
Ensure availability of hand gel.
Improve overall care rating in outpatients.
Improve nursing communication with patients.
Improve overall care rating in outpatients.
Improve cancer patient experience.
Improve cancer patient experience.
Continue to improve overall care ratings and waiting times in outpatients as measured by our local survey.
Continue to improve cancer patient experience.
Continue to improve overall care ratings and waiting times in outpatients as measured by our local survey.
Continue to improve cancer patient experience overall and in selected areas as measured by our local survey.
6
University College London Hospitals NHS Foundation Trust

2012/13
Reduce number of falls resulting in harm.
Increase VTE risk assess.
Reduce medication omissions.
Review our unplanned readmissions.
Improve our hospital mortality ratio.
2013/14
Improve our end of life care.
Improve the management of pain relief.
Reduce harm from falls,
VTE (see glossary), HAPU
& infection.
Eliminate grade 4
Hospital Acquired
Pressure Ulcers (HAPU).
Use Ward Safety
Checklist on daily ward rounds.
2014/15
Continue to improve end of life care.
Improve care of patients with dementia.
Continue to reduce harm from falls and infection.
Achieve CQUIN* targets for reducing harm from pressure ulcers.
Improve Trust wide learning from Serious
Incidents.
2015/16
Reduce surgery related harm.
Reduce harm from unrecognised deterioration.
Reduce patient harm from sepsis.
Develop clinical outcome measures specific to each specialty.
Continue to improve mortality ratio.
Continue to develop specialty clinical outcomes.
Continue to improve mortality ratio with focus on weekend mortality.
Continue Trust wide learning from Serious
Incidents.
To publish 10 specialty specific clinical outcome measures per quarter.
Maintain our position in the top 10% of trusts nationally for SHMI.
*CQUIN – see glossary
For further information on progress with 2014/15 objectives see Section 3. For further information on priorities for 2015/16 see Section 4.
Quality Account 2014/2015
7

3
In this section we describe three survey results we have used to measure patient experience – the National Inpatient Survey (CQC) results (how we compare to every NHS trust), Picker survey results
(comparing to trusts using this survey provider) and our internal real time patient feedback system, Meridian. Our aims were to improve our patient rating of overall experience and in specific areas which required improvement – explanations given to patients prior to surgery and involvement in decisions about care.
The targets we set and the results were as follows:
National inpatient survey results (CQC) – higher scores are better
Overall experience rating
(higher is better)
Were you told how you could expect to feel after your operation?
Involvement in decisions about your care and treatment
2014 target*
8.4/10
7.4/10
7.5/10
2014 Result*
8.1/10
7.3/10
7.5/10
* Individual responses are converted into scores on a scale from 0-10, with 10 representing the best possible score and 0 the worst (see glossary for further information).
However, the results from the National Inpatient Survey were not available until 21 May 2015 and we therefore used the Picker survey results and Meridian to assess our performance. The Picker Institute carries out the patient survey programmes on behalf of the Care
Quality Commission for some trusts.
8
University College London Hospitals NHS Foundation Trust

The results from the Picker survey for the questions we agreed to focus on are as follows:
National survey results (Picker) – lower scores are better
Overall experience rating
Were you told how you could expect to feel after your operation?
Involvement in decisions about your care and treatment
2013 result
(Picker)*
12%
40%
39%
2014 result
(Picker)*
13%
39%
36%
* The Picker report uses problem scores which show the percentage of patients for each question who have indicated that a particular aspect could have been improved (see glossary for further information). Lower scores are better.
765 patients of the total of 1700 patients who were asked to participate completed the survey – 46 per cent. According to the
Picker results improvements have been made in the two targeted questions but not in the overall experience rating.
As the National Inpatient Survey and the Picker survey are carried out yearly, we used Meridian to monitor our performance against these questions throughout the year. Our experience is that by including these questions in the survey and reporting on the results directly to the wards, the performance improves. We find that local surveys tend to produce better results than the national survey and so we set higher internal targets.
A total of 11488 adult inpatients completed the Meridian questionnaire between April 2014 and March 2015, a total of 35.8 per cent of eligible patients. The majority of patients are surveyed in hospital at the point of discharge although there is the opportunity to complete the survey online once the patient gets home. Data shows that 92% of patients completing the survey did so while still in hospital. The results are as follows:
Meridian survey results – higher scores are better
Question
Overall experience rating
Were you told how you could expect to feel after your operation?
Involvement in decisions about your care and treatment
2013 target
(Meridan)*
95%
86%
80%
2014 result
(Meridian)*
91%
86%
87%
* Meridian scores measure the answer as a percentage of the maximum score (see glossary for further information).
Quality Account 2014/2015
9

Results over the year are as follows:
100.00%
95.00%
90.00%
85.00%
80.00%
75.00%
Meridian performance target
Meridian scores measure the answers as a percentage of the maximum score (see glossary for further information).
The target of 95 per cent was not achieved.
100.00%
95.00%
90.00%
85.00%
80.00%
75.00%
Meridian performance Target
Meridian scores measure the answers as a percentage of the maximum score (see glossary for further information).
10
University College London Hospitals NHS Foundation Trust

The target of 86 per cent was met throughout most of the year.
100.00%
95.00%
90.00%
85.00%
80.00%
75.00%
70.00%
Performance Target
Meridian scores measure the answers as a percentage of the maximum score (see glossary for further information).
The target of 80% was met or exceeded throughout most of the year. This question was only added to the Meridian Survey questionnaire in September 2014.
Whilst the results on Meridian are often more favourable and we did well on the specific questions against our target (fig 2 and 3) the trend for overall patient experience as illustrated in fig 1 showed little improvement during the year and so we need to have a greater focus on actions that will improve our overall patient experience, using all our local data to drive improvements.
Looking at the Picker results and Meridian results together, we have not met our target to improve the overall experience rating but we have improved our survey results on the other two questions. The National Inpatient results published in May 2015 confirm that we did not meet the overall target for overall experience and that we narrowly missed our target for being told what to expect after the operation. We did meet our target for involvement in decisions about care and treatment. This suggests that we need to continue to focus on overall experience have been in. The staff were so friendly, were informed, made you feel very welcome. The ward was nice and spotless a relaxed environment.
I felt I was not fully involved in my care from the medical point of view e.g. when medication is changed I am not informed and given a chance to ask questions.
Excellent care. Found it extremely helpful that my consultant arranged for me to meet another patient who had same operation, it relieved my anxieties and prepared me for what was to come.
My operation wasn’t explained to me beforehand. I was told it was very simple and I’d be out in two days. This isn’t the case. I’ve been here six days and I have to come back for two more.
Quality Account 2014/2015
11

Our progress against the targets we set comes from our local
Meridian outpatient surveys as there is no recent outpatient survey, and is detailed in the table below – we focused on overall experience and waiting times.
To help with waiting times we introduced kiosks to make it quicker to check in and this also gives information to the team on how many patients are waiting. Other initiatives to improve outpatients include the Out Patient Improvement Project described in the introduction. A total of 4772 adult patients completed the
Outpatient Survey Meridian questionnaire between April 2014 and
March 2015, approximately 0.6 per cent of total appointments. We recognised that this is a low response rate and we piloted a new way to gather feedback using a simpler paper-based form. This saw the average responses increase by 150 per cent in the area it was tested (from 65 to 165 per month).
The results are as follows:
Meridian survey results – higher scores are better
Question
Overall how would you rate the care you received (1)
How long after the stated appointment time did the appointment start? (2)
2014
Target
86%
70%
2014
Results
89%
69%
(1) Percentage of patients who rated the care as good or better
(2) Percentage patients who waited less than 30 minutes for their appointment to start
Meridian scores measure the answers as a percentage of the maximum score (see glossary for further information).
The results over the year are as follows:
100.0%
95.0%
90.0%
85.0%
80.0%
75.0%
Meridian performance Target
12
University College London Hospitals NHS Foundation Trust

*Meridian scores measure the answers as a percentage of the maximum score (see glossary for further information).
We did meet our target of 86 per cent over the year.
75.00%
70.00%
65.00%
60.00%
55.00%
50.00%
Meridian performance Target
*Meridian scores measure the answers as a percentage of the maximum score (see glossary for further information).
We did not consistently meet this target throughout the year.
We have improved on the overall rating of care but did not achieve our target for waiting time which continues to be variable between clinics and we will continue to focus on this for 2015/16.
Very efficient. Excellent staff manner. Hardly any waiting. Well organised.
Very professional and prompt.
Courteous, explained everything very fully. Gave me confidence that they would be ‘on the case’ of my issue. I feel very looked after.
Kind staff, good medical care, waiting time too long.
I waited almost two hours to be seen.
Quality Account 2014/2015
13

Our performance in the 2014 National Cancer Experience Survey (NCPES) is detailed in the table below. 879 adult patients responded – this is a 51 per cent response rate – the national response rate was 64%.
NCPES Question – higher scores are better
Overall how would you rate the care you received
Were you given enough information about your condition
2014
National survey target*
90%
90%
2014
National survey result*
88%
85%
Were you given the name and contact number of your Clinical Nurse Specialist
Hospital staff definitely gave patient enough emotional support
92%
71%
92%
64%
*The NCPES is administered by Quality Health. In that survey the questions have been summarised as the percentage of patients who reported a positive experience. For example, the percentage of patients who said they were given enough information about their condition. Higher scores are better.
Overall, the results from the NCPES were better this year; there were more responses to questions where we were in the top 20 per cent and fewer responses to questions where we were in the bottom 10 per cent. We were pleased that we did better in patients knowing who their Clinical Nurse Specialist (CNS) was, the provision of information and confidence in ward staff. We were disappointed however that we did not improve in the specific questions above.
As the national survey is yearly or less we monitor internally using our real-time patient feedback system
Meridian and the results are as follows:
Meridian survey results – higher scores are better
Question
Overall how would you rate the care you received
Were you given enough information about your condition
Were you given the name and contact number of your CNS
Hospital staff definitely gave patient enough emotional support
Local
Survey results
(Meridian)
2013/14*
90%
88%
72%
79%
Local
Survey targets
(Meridian)
2013/14*
91%
90%
82%
85%
*Meridian scores measure the answers as a percentage of the maximum score (see glossary for further information).
Local
Survey results
(Meridian)
2014/15*
90%
93%
65%
85%
Cancer patients are asked these questions when in outpatients or day care. A total of 1209 adult patients completed the Meridian Cancer Survey questionnaire between April 2014 and March 2015, a total of 2.3 per cent of eligible patients.
14
University College London Hospitals NHS Foundation Trust

The graphs below show the results over the year.
100.00%
95.00%
90.00%
85.00%
80.00%
75.00%
Meridian performance Target
Meridian scores measure the answers as a percentage of the maximum score (see glossary for further information).
We did not consistently meet the target throughout the year.
100.00%
95.00%
90.00%
85.00%
80.00%
75.00%
Meridian performance Target
Meridian scores measure the answers as a percentage of the maximum score (see glossary for further information).
We met the target throughout most of the year.
Quality Account 2014/2015
15

100.00%
95.00%
90.00%
85.00%
80.00%
75.00%
70.00%
65.00%
60.00%
55.00%
50.00%
Performance Target
Meridian scores measure the answers as a percentage of the maximum score (see glossary for further information).
We did not meet the target throughout the year.
100.00%
95.00%
90.00%
85.00%
80.00%
75.00%
70.00%
65.00%
Performance Target
Meridian scores measure the answers as a percentage of the maximum score (see glossary for further information).
We did not consistently meet the target throughout the year.
16
University College London Hospitals NHS Foundation Trust

We did not meet the target rating for overall care in either survey. We met the target for the question relating to enough information in the Meridian survey but not in the national survey. Although we met the target for the question regarding the name and contact number of the CNS in the national survey this result was not supported in the Meridian survey. The target for the question about enough emotional support was not met according to the national survey.
We therefore agreed to continue to focus on the overall experience and the question relating to the name and contact number of the CNS as this showed the poorest results in the local survey.
My CNS is excellent, always helpful and supportive.
Medical treatment we are very happy with, it is very good.
But waiting times need to be improved and it would be nice to have some more information and emotional support from staff.
Patient has not been given a name for her CNS only a number and when they tried to call the number it was very hard to get through to anyone.
Staff very helpful, lots of useful information given, the consultant is first rate.
Quality Account 2014/2015
17

In 2014/15 UCLH received 835 formal written complaints, compared to 791 in the previous year, this represents an increase of 5.6 per cent. However, caution should be used in only looking at the actual number of complaints as we actively encourage the reporting of complaints and concerns so that we can learn and improve. New leaflets were circulated across the Trust and information on raising concerns and complaints was included in the new ‘welcome pack’
(see glossary).
We recognise that it can be very difficult for patients to raise concerns and we use our Trust induction training to tell staff the importance of giving patients time to raise concerns and to respond to them before they become complaints. In the past year we have met with Voiceability (see glossary) and
Healthwatch and have also signposted patients to their services.
In addition to the formal complaints received between 1st April 2014 and 31st March 2015 there have been 69 reinvestigations; this represents approximately a reinvestigation rate of <10%which we are planning to benchmark against the Shelford group of hospitals when the data is available.
During 2014/5 there has been a significant increase in the number of complaints investigated nationally by the Parliamentary Health Service Ombudsman
(PHSO) (see glossary). At UCLH there were 67 contacts from the PHSO. Most of these were considered premature e.g. the complaint had not been received at UCLH or was still being investigated. In 2014/15 the PHSO requested 18 complaints to investigate compared to 23 for the previous year. In 2014/15, one complaint relating to care in 2011 was partially upheld due to the length of time it had taken to offer a meeting (2013). The reason for this was multifactorial and the approach to logging requests for meetings has been strengthened to avoid similar delays in future. 12 cases for 14/15 are still under review by the PHSO.
National reporting of complaints data is expected to be revised next year, with the introduction of quarterly reports which it is hoped will offer timelier benchmarking and allow us to target areas of improvement more quickly.
The Trust is committed to learning from complaints and is continuing to explore how best to use complaints to improve care including sharing patient stories at the board.
Below are examples of improvements made as a result of patient complaints.
All complaints about nutrition, menu choice or assistance with meals are shared with the Trust’s
Nutritional Steering Group. Women’s Health post-natal ward have introduced a hotel style folder for patients to see meal and beverage choices after this featured in a wider complaint about post-natal care. The issue of halal and vegetarian menu choices being very limited was raised in recent complaints. This was discussed at the Nutritional Steering Group and work is now going on at a contractual level to improve the scope of these options for patients, with facilities, dieticians and nursing staff working together.
Following a small number of complaints a working group has been set up within Women’s
Health, including representatives from midwifery, obstetrics, gynaecology, psychology and bereavement support to review and improve the experience for access to scans, care, advice and support during and after miscarriage. The group have identified the need to update patient information and additional scanning capacity has been established for weekends. A staff educational programme has been developed and use of stickers allows easier identification so staff do not have to repeat distressing questions.
Whilst the move itself was well coordinated, complaints and feedback were received, particularly about the phlebotomy services moving to outpatients. A number of immediate actions were taken
A floor walker was introduced into main outpatients to signpost patients to different phlebotomy areas
a numbering system was introduced
patients are offered blood tests at a number of local GP practices extra space for phlebotomy was found at a neighbouring site and
a multidisciplinary group has been setup in conjunction with estates and facilities and patients have been invited to input into this.
18
University College London Hospitals NHS Foundation Trust

Quality Account 2014/2015
19

Issues from complaints are shared across the organisation to ensure we learn lessons and make improvements. Analysis of clinical themes from complaints has fed into many areas of work e.g. end of life, medication safety, discharge, pain management, disability and equality issues, nutrition and hydration, falls and pressure ulcers. This sharing ensures that any areas of concern are identified and that the experts within the committees can add to action plans or monitoring after complaints are received.
The chairman and complaints manager have held joint presentations for staff about themes from complaints, and have visited the Heart
Hospital, the National Hospital and the Eastman
Dental Hospital in the past year.
Presentations on themes have also been given to the Nursing and Midwifery Committee and the clinical boards by the complaints manager.
Last year we said we would train staff on end of life care and introduce the AMBER care bundle (see glossary) on six wards. This consists of four elements: talking to the patient and family to let them know the healthcare team has concerns about their condition and to establish their preferences and wishes, deciding together how the patient will be cared for should their condition worsen, documenting a medical plan and agreeing these plans with all the clinical team looking after the patient.
We also said that we would monitor the number of patients who have the Preferred Place of Care (PPC) recorded and we would develop and use a survey.
We have set up an EOLC Board which oversees the work of the Transforming EOLC team. We have trained 253 staff on 5 wards in the use of important aspects of EOLC including AMBER care bundle,
Advance Care Planning, Rapid Discharge guidelines,
Co-ordinate My Care and Care in the last days of life.
We have been unable to identify a robust way to ensure that the preferred place of care of patients within UCLH is recorded. However, the Electronic
Palliative Care Coordination System, Co-ordinate My
Care (CMC), is being introduced to the Trust, and we will continue to work on this.
We have developed a survey that will be given to all relatives when they attend the hospital to collect the death certificate of a loved one, to obtain an
20
University College London Hospitals NHS Foundation Trust assessment of the care of patients who die at UCLH.
We are also developing a survey to assess how ward staff feel about the care of patients who die at UCLH.
This priority is now well established in the Trust and has a board and a reporting structure up to and including the Executive Board. Priorities for 2015/16 have been agreed – these include training staff on a further 13 wards in the important aspects of EOLC
(see above), reducing the 30 day readmission rate of those patients discharged from UCLH, and improving the experience of bereaved relatives. It was therefore decided that sufficient processes have been put in place to ensure that this remains a key area within the
Trust and that it no longer needs to be included as a quality account priority.
Last year we said that we would ensure that specified wards will provide a dementia friendly environment and we would look at further environmental changes.
We said that staff on the Acute Medical Unit (AMU),
Elderly Care Ward (T7) and A&E will have received dementia management training and the future training plan will be in progress.
This year a number of environmental changes have taken place on the wards on the UCH site. These include:
Changing a bathroom on T7 (Elderly Care ward) into a reminiscence room providing a place to rest and relax away from the busy ward areas
all toilet doors on wards most frequently used by people with dementia are now pale blue with a red toilet sign to enable people to find their way to the toilet independently
the bays on T7 have been colour co-ordinated; the curtains in each bay are a different colour to assist patients to find their bed area there are digital radios in all side rooms and ward bays on AMU, T7, Hyper-Acute Stroke Unit (HASU) and T8 (Infection ward) for entertainment. Digital radios provide access to foreign language stations reducing the feelings of isolation for non-English speaking patients. It also has helped patients feel less isolated with some background music large clocks displaying time, AM/PM and date have been placed on the walls in all bays and side rooms in AMU, T7, HASU and T8 and in the cubicles in the emergency department to help with the patient’s orientation on T7 there are wall mounted games and reminiscence photos on the walls to provide points of interest and help patients find their way
AMU, T7, HASU and T8 have been furnished with

an array of appropriate books, playing cards, flash cards, pens and paper, letter writing equipment, shoes and polish etc. to provide stimulation and a sense of purpose.
These improvements, except the reminiscence room, are now being rolled out across the relevant wards at the National Hospital for
Neurology and Neurosurgery. The Emergency
Department rebuild will also be dementia friendly.
In August, mandatory e-learning (see glossary) was launched for all nursing staff, allied health professionals and patient facing staff.
Over 3500 staff members have completed the course. The interactive content dispels common myths about dementia, explains the different types of dementia and describes the signs and symptoms. As part of the session
‘Barbara’s story’ is shown. ‘Barbara’s story’ was made by Guys and St Thomas’ Hospital to raise awareness on how it feels to be a patient with dementia. The story follows Barbara through an outpatient appointment and admission to a ward. The emphasis is on the importance of kindness and good communication.
As well as e-learning, advanced face-toface training will continue. This consists of one and two-day courses for front-line staff, including medical and therapy staff. The number of courses will increase next year to meet the increasing demand. Bespoke training will continue for departments – for example theatres, out- patients, transport and pre-assessment. Dementia training is part of medical and nursing students’ education programme as well as preceptor nurses and these will continue too.
In areas identified as most likely to look after patients with dementia, 800 staff have undertaken either the one day or in most cases, 3 day face-to-face training in addition to staff who have undertaken the e-learning package.
We are pleased with the progress on the care of patients with dementia and this will continue to be a high priority in the organisation. Our processes are well established and we did not consider that it needed to be highlighted in the quality account for a further year.
Reminiscence room T7
New toilet doors
Wall mounted game
Quality Account 2014/2015
21

In 2014/15 we continued our focus on three areas of avoidable harm – falls with harm, hospital acquired pressure ulcers and infections.
Our aim was to reduce the number of falls with harm by 10 per cent by the end of the year. We based our target on the first quarter. This was because we changed how we report falls with harm in line with recent guidance (we added in ‘unwitnessed’ and ‘medical collapse’ related falls) from April 2014.
Overall falls numbers reported have decreased from an average of 23 per month in the first quarter to an average of 20 per month in the last quarter, so achieving a 14 per cent reduction.
However, this remains a high priority in the organisation. Our falls group, chaired by a consultant specialising in care of the elderly, with physiotherapy and nursing members, has introduced a number of falls prevention initiatives, including a new way to help with assessment of patients and planning care, and guidance on how to care for patients after a fall.
Technology, such as seat cushions with noise alerts if a patient gets up, is being tested.
All falls are being reviewed weekly by our expert ‘Falls Group’ to monitor the level of harm patients have experienced and prompt changes and investigations as necessary. Falls will remain a key focus for us – the falls group is now well established and we are continuing to train staff to become
‘falls champions’ and are continuing to raise falls prevention awareness.
We will continue to report monthly on progress at meetings with our commissioners (see glossary) and at the Board. Our processes are well established and we did not consider that it needed to be highlighted in the quality account for a further year.
The Trust Board takes falls very seriously – and, as part of a ‘Board Safety Series’, the topic will be the subject to a Board of Directors review and presentation on progress and next steps in May 2015.
UCLH compares favourably against our peer
English teaching hospitals for rates of falls (falls per 1000 bed days, compared with top-ten English teaching hospitals); however – our ambition is clear
– to reduce falls to the absolute minimum and to have the lowest level of harm events (related to falls) amongst our peer hospitals. For 2015/16 we have set ourselves a further stretch target of reducing harm events related to falls by a further 15 per cent this financial year (building on the 14 per cent reduction last year).
22
University College London Hospitals NHS Foundation Trust

45
40
35
30
15
10
25
20
5
0
Apr May Jun Jul Aug Sep Oct Nov Dec
Low harm caused Moderate harm caused to paent
Incident casued/contributed to permanent or long term harm Incident caused/contributed to death
Jan Feb Mar
We said we would meet our CQUIN target of a reduction of grade 3, 4 and 5 hospital acquired pressure ulcers (HAPUs) by 50 per cent. During 2014/15 we have achieved a further reduction from last year and met the CQUIN target for quarter
1 and 2 and 80 per cent of the CQUIN target for quarter 3 and quarter 4. We have had no grade 4 pressure ulcers.
A key aim of this year’s plan is to further enhance our collaboration with community colleagues, recognising that successful pressure ulcer reduction requires an entire health economy approach.
Our sustained reductions in HAPUs represents the effort and commitment to high quality care shown by all clinical teams across the Trust. Our pressure ulcer prevention team continues to work with matrons, sisters and ward staff to raise awareness and improve the preventative care of patients at risk of pressure damage.
Like falls, this remains a high priority in the organisation. Our processes are well established and we did not consider that it needed to be highlighted in the quality account for a further year.
30
25
20
15
10
5
0
Category4 2014/15
Category3 2014/15
Category2 2014/15
Target for Category 2 and above
All Pressure Ulcers 2013/14
April
0
0
6
9
17
May
0
3
4
9
24
June
0
0
6
9
20
July
0
2
9
9
13
August September October November December January
0 0 0 0 0 0
0 0 0 1 0 2
3
9
13
4
9
16
2
8
14
11
8
7
8
8
11
3
7
9
February
0
2
3
7
14
March
0
2
5
7
6
Quality Account 2014/2015
23

Clostridium difficile
Clostridium difficile is an infection of the large bowel which causes diarrhoea and inflammation of the gut.
It is often associated with antibiotic use which disrupts the normal bacteria in the gut.
The Clostridium difficile micro-organisms may contaminate the environment, can be spread by hands and consumed on food. It is possible to prevent the development and transmission of Clostridium difficile by careful antibiotic prescribing, scrupulous cleaning, isolation of patients with Clostridium difficile and hand hygiene with soap and water.
It is not possible to prevent all cases of Clostridium difficile . An increasing proportion of our patients are admitted with Clostridium difficile (carriers). In some cases the use of antibiotics is essential such as patients being treated for cancer with an infection or to treat significant infections. These patients are at risk of developing Clostridium difficile infections when they are given antibiotics.
At UCLH we screen all patients with diarrhoea for
Clostridium difficile unless another cause is known.
We screen 20 per cent more patients for Clostridium difficile than trusts generally. This is because early identification and treatment improves patient outcome.
UCLH reported 109 cases of Clostridium difficile in 2014/15. 80 of these cases have been successfully appealed as not being lapses in care. 20 cases are still under review. Nine cases of Clostridium difficile have been found to be a lapse in care by the Trust.
Therefore we have stayed within our threshold set of
71.
In common with most UK hospitals and in line with national guidance the key interventions used to prevent and control Clostridium difficile by UCLH include antibiotic stewardship and careful review of the continuing requirement for antibiotics; monitoring of stools using the Bristol stool chart for early identification of diarrhoea; rapid stool sampling and testing in the presence of diarrhoea and isolation in a single room until a cause is found or the infection risk has ceased and the use of personal protective equipment and hand-washing.
We also ensure appropriate and timely treatment and support including new treatments such as faecal transplants (see glossary) in persistent infections. We also review the use of Proton pump inhibitors (see glossary) and other drugs which may contribute to the development of Clostridium difficile ; use including hydrogen peroxide vaporization and deep cleaning for the enviromment. Information and education of staff, patients and visitors, feedback of learning from
24
University College London Hospitals NHS Foundation Trust the RCAs (see glossary) and Board level awareness and support of Clostridium difficile reduction efforts are also very important.
MRSA bacteraemia
MRSA bacteraemia is an infection of the blood. The target was zero and UCLH has had three cases this year which is a reduction on last year‘s total of six cases.
This year’s cases were due to poor intravenous
(IV) line insertion and care. UCLH now has a nurse specialising in intravenous lines, who trains staff in inserting and caring for lines and who investigates the causes of bacteraemia.
A new tool to improve documentation has recently been introduced and a pack has also been introduced which ensures the samples are taken properly.
However, we recognise that still more needs to be done.
Current plans are to recruit and train “champions” from each specialty so that they can monitor and support good IV line care.
We aimed to provide monthly safety reports to all clinical areas which include overall incident data and summaries of serious incidents including case studies, and learning to prevent recurrence. We also wanted to encourage serious incident discussions at all quality and safety (governance) meetings.
Regular incident analysis reports have been circulated to staff in the UCLH. The reports include overall incident data and a focus on the areas of highest reporting such as pressure ulcers and medicines. Case studies have been included. The internal Quality and Safety bulletin which is circulated to staff has been used to share learning, from serious incidents in particular. Discussions have taken place with the web team to develop a specific site on
Insight, the internal website, for access to information on serious incidents and learning.
A ‘Quality Forum’ in February 2015 was focused on serious incident case studies and the importance of understanding how policies and procedures which affect patient safety are followed in practice.
We reviewed the guidance for staff on what to include in the local quality and safety meetings, ensuring a greater focus on learning from incidents, complaints and claims and this is being implemented.
We undertake multidisciplinary ‘Improving Care walk rounds’ to help staff and management teams to improve their services. The purpose of the walk rounds is not to criticise, but to promote improvement

in care, environment and services by coming into the area with ‘fresh eyes’. Questions we always ask staff on the walk rounds are: ‘What was the last serious incident in the division?’ and ‘What did you learn from it?’.
Any immediate concerns and areas of excellence identified by the walk round team are fed back to the divisional management team at a debrief meeting after the walk round. A detailed report of all findings and observations is prepared for the management team and the medical director. The divisions draw up an action plan to address any identified concerns and this plan is monitored by the relevant clinical board.
We promote After Action Reviews (AAR). These were introduced to UCLH in 2008 as a universal approach to improving patient safety and the quality and effectiveness of our services. AAR is a group discussion which is structured around four simple questions:
What was expected? (there is sometimes no plan but there is always some form of expectation)
What actually happened?
Why was there a difference?
What can we learn as a result?
These are underpinned by a set of ground rules and specifically focused on seeking to learn after an event rather than blame.
AARs can take many forms, from a very formal three hour meeting to a 10 minute debrief and are being widely used in clinical and non-clinical areas of
UCLH and other NHS organisations.
AAR is now established as widespread practice with front line teams as a learning and debrief tool.
Quality Account 2014/2015
25

The SHMI (Summary hospital-level mortality indicator) is 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 here. It includes deaths which occur in hospital and deaths which occur outside of hospital within 30 days
(inclusive) of discharge – ‘external SHMI.’
The Health and Social Care Information Centre (HSCIC) release the external
SHMI every quarter but there is a six month time lag. The latest external SHMI released in April 2015 was for the period October 2013 to September 2014. A review of the SHMI analysis for the period covering July 2011 September 2014 is shown below.
In addition to the above, we also monitor an ‘internal SHMI’ which only includes deaths in hospital. This data is available to us on a monthly basis and does not have a time lag.
Since 2013, we have seen an increase in the Trust’s external SHMI whilst the internal SHMI has remained relatively steady.
The chart below shows the trend of the external SHMI over time (a lower number is better):
1.4
1.3
1.2
1.1
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Jul 11 to Jun
12
SHMI 0.71
Naonal average 1.0
Oct 11 to Sept
12
Jan 12 to Dec
12
0.68
0.71
1.0
1.0
Apr 12 to Mar
13
0.71
1.0
Jul 12 to June
13
0.74
1.0
Oct 12 to Sept
13
0.75
1.0
Jan 13 to Dec
13
0.76
1.0
Apr 13 to Mar
14
0.80
1.0
Jul 13 to June
14
0.78
1.0
Oct 13 to Sept
14
0.79
1.0
When looking at our internal SHMI there is less change; it has remained steady at an average of 0.50 for the past 20 months. This suggests that deaths outside of hospital within 30 days of discharge may be increasing. Deaths within 30 days of discharge for elective admissions have increased slightly since the publication of the October 2012 to September 2013 external SHMI.
We know from the Care Quality Commission Intelligent Monitoring Reports that our weekend mortality ratio is within the expected range and that weekday mortality is less than expected.
26
University College London Hospitals NHS Foundation Trust

1.8
1.7
1.6
1.5
1.4
1.3
1.2
1.1
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
Local SHMI - Relative Risk - (1 yr rolling data)
National Average
Apr-14
0.52
1.00
May-
14
0.53
1.00
Jun-14
0.52
1.00
Jul-14
0.53
1.00
Aug-
14
0.48
1.00
Sep-
14
0.53
1.00
Oct-14
0.52
1.00
Nov-
14
0.52
1.00
Dec-
14
0.52
1.00
Jan-15
0.51
1.00
Feb-15
0.53
1.00
Mar-15
0.51
1.00
As the HSCIC release the external SHMI data by diagnosis group, we are able to identify which diagnosis groups have had the most increase above the expected rate. The relevant divisions will continue to review the deaths in these diagnosis groups and we have decided to keep this as one of our priorities – see Section 4,
Priority 3
We said that we would aim for all specialties to have three identified clinical outcome measures, that data will be available against each indicator and that benchmarking data will be provided for at least one indicator.
Specialties have begun to do this and are completing a template of information explaining outcome description and rationale and including performance graphs.
The challenges have been in finding robust benchmarking data. We will continue to work on this and have started to publish the data on our external website – go to www.uclh.nhs.uk/cci
Quality Account 2014/2015
27

4
We will continue to improve clinical outcomes.
In order to determine our priorities we have consulted
We will: with a number of stakeholders including our Trust
publish 10 specialty specific clinical outcome
Quality and Safety Committee (QSC), clinical boards, measures per quarter our commissioners and GP representatives through
maintain our position in the top 10 per our Clinical Quality Review Group and our governors cent of trusts nationally for the mortality
(see glossary). The QSC on behalf of the board indicator SHMI (Summary Hospital-level approved the priorities and there will be regular
Mortality Indicator) reports on progress to the QSC throughout the year.
We have ensured that our quality priorities are aligned with this year’s UCLH top ten objectives for patient safety, experience and clinical outcomes and we have taken into account our progress throughout the year against last year’s priorities to help decide which priorities need an ongoing focus within this year’s quality account. The following have been agreed:
There are a number of national patient experience surveys and we have chosen to continue to focus on three areas as part of our quality priorities – inpatients and outpatients as these patients are seen across UCLH and cancer patients as cancer services is an area of development for us and where we see the need for most improvement. We wish to improve the overall ratings experience ratings as well as in selected areas as measured by national and local surveys.
We know that good patient experience has a positive effect on recovery and clinical outcomes. To improve that experience we need to listen to patients and respond to their feedback and in our view this is central to caring for our patients. To this end we run continuous real-time surveys which provide valuable feedback to clinical teams about the care in their area. This is supplemented by national patient surveys which allow us to benchmark ourselves nationally and within London.
We will focus on the following ‘Sign up to
Safety’ pledges: (see glossary)
To reduce surgery related harm
To reduce harm from unrecognised deterioration
To reduce patient harm from sepsis
Continually learn – continue to focus on improving UCLH wide learning from serious incidents.
28
University College London Hospitals NHS Foundation Trust

Our aim is to drive continuous improvement in patient experience to become one of the best in the country. In addition to work by individual wards and departments, we target particular aspects of care each year based on national and local survey results.
We want to improve our patient rating in overall experience in the national inpatient survey and continue our improvement programmes for cancer and outpatient experience.
As national surveys are published yearly or less we measure our performance using our real time patient feedback system (Meridian). This provides monthly feedback which is shared with all the clinical teams.
At a UCLH level this data is reviewed at the Cancer
Clinical Steering Group and the Patient Experience
Committee as well as the Quality and Safety
Committee. We will also be linking this to our ‘Future
UCLH’ programme of improvement in the coming years.
A national Inpatient survey is conducted each year and published on the CQC website. The survey results are benchmarked against all NHS trusts and therefore allow national comparison. Our aim is to achieve year on year improvement on the question which asks patients to rate their overall experience on a scale of
0 – 10 with 10 being “a very good experience”.
In addition each year we target specific areas where patients have told us that experience could be improved. The national inpatient survey results were published too late for us to consider the areas to focus on for next year through our internal and external consultation process so we selected two questions based on the Picker survey – areas where we have worsened significantly compared with last year. Since we agreed these questions the national inpatient survey results have been published. We reviewed the results and confirmed that the areas we had chosen were areas we needed to focus on but we also decided to add a further question where we had not done well – ‘did not always get enough help from staff to eat meals’
In summary the areas we agreed are as follows with targets:
National survey results
(Picker) – lower scores are better
Overall experience rating ( scored less than 7/10)
Care: Staff contradict each other
Care: More than 5 mins to answer call button
Hospital: did not always get enough help from staff to eat meals
National inpatient survey results (CQC) – higher scores are better
Overall experience rating (1)
Care: Staff contradict each other (2)
Care: More than 5 mins to answer call button (2)
Hospital: did not always get enough help from staff to eat meals (2)
2014 result*
13%
37%
20%
41%
2015 target*
12%
30%
14%
37%
* problem scores – lower scores are better. See glossary for more information on how these are calculated.
The targets chosen are based on previous best performance over the last four years (in the same survey)
As overall experience is already above average compared with other trusts in the Picker survey we want to maintain this performance.
The results from the national inpatient survey and the targets are as follows:
2014 result*
8.1
7.7
6.0
6.5
2015 target*
8.4
8.2
6.2
7.9
* Individual responses are converted into scores on a scale from 0-10, with 10 representing the best possible score and 0 the worst (see glossary for further information).
1 Maintain the target from last year
2 Target is last year’s score
Quality Account 2014/2015
29

We know from experience that by including these questions in our real time patient experience survey, performance will improve as ward teams are able to try ways to improve patients’ experience in specific areas and see quickly whether there is an impact.
We also believe that our ‘Home for Lunch’ initiative will help with staff not contradicting each other. This is a system of ‘planning for tomorrow’, where ward staff meet as a multi-disciplinary team
(MDT) to review all patients on their ward, establish their progress and ensure that all plans for discharge are in place. Ensuring everyone is clear about patients’ plans and progress also makes for more consistent information being provided to patients and relatives by the members of the MDT.
We have started to look at best practice in other trusts for helping patients with meals and have areas of good practice within the trust that we can learn from. We will use this experience to agree a plan to implement improvement in all areas.
idea of how we are doing. At present, very small numbers of patients respond to our feedback survey offered on tablets or online. We have trialled alternative ways of providing feedback (e.g. a paper form) and initially want to increase responses to at least 1 per cent while we agree the right system to use. We are also asking patients more frequently about our service so that we can take prompt action.
We have also undertaken further UCLH wide work to improve the booking/contact processes including administration, management on the day, and staff attitudes, all of which are aimed at improving our outpatient experience and efficiency.
Our performance and targets are as follows:
Meridian survey results
– higher scores are better
Question
Overall how would you rate the care you received (1)
How long after the stated appointment time did the appointment start? (2)
2014 result
(Meridian)
89%
69%
2015
Target
(Meridian)
91%
74%
Last year patients attended 940,000 outpatient appointments and it is important to us that this should be a positive experience. We have been working with clinical teams in a structured programme called the ‘Productive Outpatient
Programme’ (POP). POP works to improve the quality, efficiency and smooth running of clinics and improve the experience of patients who visit us.
We are continuing to work on initiatives that will make the waiting time shorter and each waiting area is being reviewed to ensure that when waits are unavoidable, patients are made as comfortable as possible and kept informed. We have introduced pagers in most outpatient areas to call patients who have impaired hearing, and to allow patients to leave the waiting areas if waits are long.
We have been working with clinic teams to give them tools to understand what patients want and supporting them to develop and test solutions to improve the experience in their services. We have made some improvement in the overall rating of care that patients received but we did not meet the target for the time patients waited. However, we want to do better and have therefore set a higher target. There is no national survey planned this year, and the last data is from 2011 so local surveys are being used to measure how we are doing.
We also want to increase the number of patients that respond to the survey so that we get a better
(1) Percentage of patients who rated the care as good or better
(2) Percentage of patients who waited less than 30 minutes for appointment to start.
The Trust continues to work to improve the cancer patient experience and we are pleased to note a number of improvements in key areas. We continue to work with our staff and patients to address issues raised by the survey and we have set targets that reflect areas which we feel are particularly important to patients.
We have set our targets based on the results of the
National Cancer Patient Experience Survey (NCPES) as follows:
30
University College London Hospitals NHS Foundation Trust

NCPES Question – higher scores are better
Overall how would you rate the care you received (1)
How easy is it for you to contact your Clinical
Nurse Specialist (CNS)?
(2)
While you were in hospital did the doctors and nurses ask you what name you prefer to be called by? (3)
If your family or someone else close to you wanted to talk to a doctor, did they have enough opportunity to do so? (4)
NCPES 2014 result*
89%
69%
54%
65%
2015 target*
91%
74%
60%
68%
Continue to train Clinical Nurse Specialists (CNS) in ‘Holistic Needs Assessment’ (HNA) – a process in which there is general discussion with patients to ensure that their needs are met and their worries and fears are discussed
continue with ‘Sage and Thyme’ (see glossary) training in particular for front line and administrative staff. This training helps staff to be more able to deal with patients’ anxieties provide training for ward staff in caring for cancer patients and for senior doctors and nurses in communication skills
provide dedicated administrative support to help
CNSs to manage telephone calls so that they can be contacted more easily by patients and more time can be spent with patients and their families.
encourage CNS teams to develop generic email addresses for patients to use e.g. gynae@uclh.nhs.uk
continue with the ‘Cancer CNS Community of
Practice’, a meeting of Cancer CNSs, used to share ideas and solutions.
*The National cancer experience survey is administered by Quality Health. In that survey the questions have been summarised as the percentage of patients who reported a positive experience.
For example, the percentage of patients who said they were given enough information about their condition.
(1) We have chosen a target based on the top 20 per cent trusts.
(2) Contact with a CNS: we have demonstrated that patients now know who their CNS is but we still have a problem with patients being able to contact them.
We have based our target on the national average of
73 per cent.
(3) Preferred name: this is still only 54 per cent in the
National Cancer Patient Experience Survey (NCPES) and we believe we should be able to improve this number. We have based our target on the national average of 60 per cent.
(4) Family able to talk to a doctor: this is an important component of quality care, and scored 65 per cent in
NCPES in 2014. We have based our target on being higher than the national average of 67 per cent.
We would like to improve our response rate as we have had less than 100 patients surveyed per month since October. However this is challenging and we are looking at other ways of getting feedback such as focus groups.
Flo Panel-Coates, Chief Nurse
Gill Gaskin, Medical Director, Specialist Hospitals
Board
There will be no NCPES in 2015 and so we will monitor our performance against our real time patient survey system Meridian.
To help us improve the overall experience and how we do against the specific questions we will:
Quality Account 2014/2015
31

Sometimes during surgical procedures things go wrong and we encourage our staff to report when this happens so that we can learn and prevent recurrence. We also ask them to tell us about near misses – something which if it had may have caused harm. Looking at near misses is seen as a good way of preventing harm. We also call these ‘good catches’.
A review of data already reported shows 14 incidents per month which may have caused harm, for example surgical instruments unavailable or delays due to bed availability, and 48 per month which cause no harm of which 8 are near misses.
We also know from our staff that improvements could be made in the way people work together and tackle problems to improve safety in theatres.
We would like to increase our overall incident reporting rate and in particular the reporting of near misses. This will give us more information to help us learn how to make surgery even safer. We will focus on the use of the WHO Surgical Safety Checklist (see glossary) in operating theatres making sure that it is routinely used in all operations. In particular, we aim to encourage a team brief at the start of the day, and also a debrief to discuss issues (good or bad) when the surgical list is complete. We want to help develop a good safety culture in operating theatres and help theatre staff deal with issues as a team so that, for example, even junior members of theatre teams are confident to speak up and raise concerns.
Success will see an increase in the number of incidents and near misses reported. Whilst we want to see this increased reporting, we want to see a reduction in incidents which lead to harm.
We will introduce a process in each theatre where trained observers will look at what goes well and what could be done better when observing the use of the WHO Surgical Safety Checklist. The results will be fed back to the teams. We will look at measuring improvement in the number of briefings and debriefings that are carried out, collaborative cross checking in theatre teams (i.e. where one team member intervenes when there is a safety problem), and team behaviours relating to eliminating distractions and interruptions during safety critical checks.
We will be able to measure improvement in the use of the Checklist from observational audit.
Our targets over three years as part of our safety plan are:
10 per cent increase in reporting incidents of surgical harm
10 per cent increase in near misses being reported
(within the 10 per cent increase)
50 per cent reduction in incidents leading to harm
observational audits of checklist use which over time identify improvement in the use of the checklist and associated behaviour in all our theatres.
Performance will be measured and monitored by the
WHO Surgical Safety Steering Group and reported to the Quality and Safety Committee.
Through our quality improvement work we have achieved a 50 per cent reduction in the number of patients who suffer a cardiac arrest. We want to sustain this improvement.
We recognise that areas to focus on now are improving the reliability with which vital signs, i.e. heart rate, blood pressure, temperature and breathing rate (respiratory rate) are recorded and the communication between teams when a patient’s condition deteriorates.
A systematic review of our harm data identified
1.3 incidents with harm per month caused by unrecognised patient deterioration.
We want to reduce patient harm caused by failure to recognise patient deterioration by improving early recognition of at risk patients – making sure that vital signs are being reliably recorded – and improving the communication to medical and senior nursing staff when a patient is at risk of deteriorating so that urgent action can be taken.
We want to see an overall reduction in the frequency of incidents leading to harm from unrecognised
32
University College London Hospitals NHS Foundation Trust

patient deterioration and we want to maintain our reduction in the number of patients suffering a cardiac arrest at UCLH. We also want to measure that the vital signs charts are being completed.
Our targets over three years as part of our safety plan are:
96 per cent vital signs completed per patient / per ward, based on a sample of 10 per ward per month
90 per cent patients escalated to the Patient
Emergency Response and Resuscitation Team
(PERRT) using an agreed communication tool
20 per cent reduction in the mean number of incidents reported per month leading to harm.
Performance will be measured and monitored by clinical boards and the Deteriorating Patient Group and reported to the Quality and Safety Committee.
Sepsis is a common and potentially life-threatening condition triggered by infection. If not treated quickly, sepsis can lead to multiple organ failure and death. Successful management of sepsis requires early recognition and treatment. We have chosen to focus on this as we have data that suggests that it is a cause of harm at UCLH.
Like many other trusts, we do not have a clear understanding of the number of patients harmed by sepsis. We do know from an audit carried out at one UCLH site in a two week period in May 2014 that
34 patients with sepsis were referred to the Patient
Emergency Response & Resuscitation Team (PERRT) or directly to critical care. Extrapolated up, this would mean 884 sepsis-related PERRT/critical care referrals at
University College Hospital in a year.
We therefore know we need to address the harm caused by sepsis, but we will need to start by understanding our baseline level of harm. We recognise that some trusts have got good data and good approaches to managing sepsis and we will seek to learn from them and develop a plan based on their experiences. This will identify what we can hope to achieve by the end of year one and subsequently as part of our three year plan.
We will have established a baseline of the number of patients with sepsis and the number of deaths relating to sepsis from which to measure progress.
Using the experience of other trusts, we will agree a target for training staff and how and what to measure during the patient’s pathway of care to ensure reliable, effective management and improved outcomes.
We will initially focus training and education on the recognition and treatment of sepsis by staff in areas where the majority of patients with sepsis will be seen (such as the emergency department).
We will continue to focus on the recording of vital signs as described in priority 2; and work to ensure that there is a reliable, early identification of patients with sepsis, and that 95 per cent of appropriate patients receive all elements of an agreed bundle of interventions within the designated time. We will undertake this work over three years as part of our safety plan. This will be aligned with the national
CQUIN.
Performance will be measured and monitored via clinical boards and by the Sepsis Steering Committee and reported to the Quality and Safety Committee.
We chose this as a priority last year due to the value and importance of learning from serious incidents
Quality Account 2014/2015
33

and in particular ‘never events’ (see glossary). We also knew from our CQC inspection in December 2013 that staff did not always know about recent serious incidents or the actions that had been proposed if they worked in areas not directly affected. This means that staff cannot use this information to learn from and make changes to improve patient safety.
Although we made progress last year there is still more work to be done.
We are trying to improve the learning and subsequent changes in practice from serious incident investigations, in particular across UCLH and not just in one area. For example this year a group of doctors, dieticians and nurses considered the problem of the misplacement of nasogastric (NG) tubes. These are tubes used for feeding being put in the lungs instead of the stomach by mistake. This is a ‘never event’. The learning from several serious incidents at UCLH led to a revision of the nasogastric tube feeding policy which included the adoption of good practice from one area
– using a chart for checking that the NG tube was in the correct place. We would like to see more examples of UCLH wide learning occurring. We will also focus on timeliness of serious incident reports following an incident investigation to ensure that learning can be shared as soon as possible.
Monthly quality and safety bulletins to continue and to include a ‘good catch’ story every month to encourage learning from near misses. We will also add a more in-depth focus on a learning topic every quarter.
Publication of learning from serious incidents on our website.
At least two quality forums per year focusing on safety.
Each Medical Board to identify cross UCLH learning from at least one serious incident and through the medical directors ensure UCLH wide implementation of changes to practice. Assurance to be built into the audit plans.
Education services will support teams in sharing their learning from After Action Reviews more widely. It will create a store of AAR summary reports that will be available to users of the UCLH intranet. After Action Review training will be offered both as a standalone programme, and integrated into a wider quality improvement curriculum
Achieve the national guidelines for investigation reports being completed following a serious incident (60 working days)
Have no ‘never events’ reported
Continue with improving care rounds and the focus on learning.
Performance will be measured and monitored by the
Quality and Safety Committee.
Sandra Hallett, Director of Quality & Safety
34
University College London Hospitals NHS Foundation Trust

Last year we worked with specialties to develop three clinical outcome measures for each specialty.
Clinicians were asked to outline the objectives they are measuring for that clinical outcome, the rationale for that objective, the results at UCLH and a commentary which includes any comparison with national benchmark data.
We want to continue our work in developing these and to publish them.
We want to be transparent with patients about how we are doing. We also believe this data will encourage specialties to set objectives to improve their performance and work towards the best performance compared with any external benchmark.
We will aim to publish on our public website 10 specialty specific clinical outcome measures per quarter. Please see the UCLH website for the latest indicators – www.uclh.nhs.uk/cci
We will monitor this via the Clinical Outcomes Group and report to the Quality and Safety Committee. of the lowest mortality ratios nationally and wish to continue this focus in line with the Secretary of State’s ambition to have no avoidable deaths.
Our other quality priorities will help with our aim to maintain a low mortality rate by focusing on deterioration and sepsis.
We will monitor our performance against the national data – SHMI is produced and published quarterly as an official statistic by the Health and Social Care
Information Centre (HSCIC). Success will be measured by our continued low mortality. We will continue to undertake a review of deaths in those specialities that show a death rate that is higher than expected to identify those which might have been avoidable, to enable learning.
We will monitor this via the UCLH performance scorecards and clinical board reviews and report to the Quality and Safety Committee.
Sandra Hallett, Director of Quality and Safety
Tony Mundy, Medical Director, Corporate Services
Hospital mortality ratios compare the actual number of patients who died following treatment at a Trust with a number who would be expected to die, based on the national average death rates in England and the particular characteristics of the patients treated.
We are proud of our record of consistently having one
Quality Account 2014/2015
35

All providers of NHS services are required to produce an annual quality account (report) and certain elements within it are mandatory. This section contains the mandatory information along with an explanation of our quality governance arrangements.
The quality governance arrangements within
UCLH ensure that key quality indicators and reports are regularly reviewed by clinical teams and by committees up to and including the Board of Directors. There are a number of committees and executive groups with specific responsibilities for aspects of the quality agenda, which report to the UCLH Quality and Safety Committee. The
Executive Board Performance Board reviews quality performance monthly. In addition, the Performance
Committee, consisting of Non-Executive Directors and
Executive Directors, monitors in detail performance against UCLH Top 10 Objectives. The committee selects those with poor performance and requests an in depth review – a recent example being Referral To
Treatment targets. The Audit Committee is responsible on behalf of the Board for independently reviewing the systems of governance, control, risk management and assurance. The Board of Directors receives a monthly corporate performance report (available on the UCLH website as part of the published Board papers) that includes a range of quality indicators across the three domains of patient safety, experience and clinical effectiveness (outcomes). In addition the Board receives quarterly reports in areas such as serious incidents, and quarterly and annual reports in areas such as child safeguarding and complaints.
The Board is further assured by reviews undertaken by internal audit which this year has included CQC governance – looking at how the Trust ensures compliance with the CQC standards.
In addition, board members including the chairman and chief executive, medical directors, chief nurse, and non-executive directors, regularly undertake walkabouts around the Trust talking to staff and patients. They focus on the CQC essential standards of safe, effective, caring, responsive and well led. These visits and what is learnt provides additional assurances on services. There are other visits – matrons undertake ‘quality rounds’ and the governors visit clinical areas.
During 2014/15 University College London Hospitals
NHS Foundation Trust provided and/or subcontracted
60 relevant health services. University College London
Hospitals NHS Foundation Trust has reviewed all the data available to them on the quality of care in all of these relevant health services. The income generated by the relevant health services reviewed in 2014/15 represents 100% of the total income generated from the provision of relevant health services by University
College London Hospitals NHS Foundation Trust for
2014/15.
Clinical audit is an evaluation of the quality of care provided against agreed standards and is a key component of quality improvement. Its aim is to provide assurance and to identify improvement opportunities. UCLH NHS Foundation Trust has a yearly programme of clinical audits which includes 3 types of audit:
1. National clinical audit , where the Trust aims to participate in all applicable audits. The full list of these and University College London Hospital NHS
Foundation Trust participation is shown in the table below.
2. Corporate clinical audit, where we set a list of clinical audits that all specialties should carry out based on Trust priorities.
3. Local clinical audit, that is determined by clinical teams and specialties and which reflect their local priorities and interests.
Audit findings are reviewed by clinical teams in their quality and safety (Governance) meetings, as a basis for peer review and for targeting or tracking improvements. A Clinical Audit and Quality
Improvement Committee oversees the corporate clinical audit programme and activity, and reports directly to the Quality and Safety Committee.
During 2014/15, 40 national clinical audits (NCA) and 2 national confidential enquiries (NCE) (four studies) covered relevant services that University
College London Hospitals NHS Foundation Trust provides. During that period, that University College
London Hospitals NHS Foundation Trust participated in 100% of the national clinical audits and 100% of national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that University College
London Hospitals NHS Foundation Trust was eligible
36
University College London Hospitals NHS Foundation Trust

to participate in during 2014/2015 and the national clinical audits and national confidential enquiries that
University College London Hospitals NHS Foundation Trust participated in, and for which data collection was completed during 2014/15 are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.
1
Audit
National Prostate Cancer Audit
UCLH eligible

UCLH participation
Yes
Cases submitted
Percentage of cases required
Not applicable
2
3
4
5
Lung Cancer (NLCA)
National bowel cancer audit programme (NBOCAP)
Oesophago-gastric cancer audit




Yes
Yes
Yes
Yes
1st round of data collection in progress
Cardio-thoracic:
19
Invasive Lung:
184
139
60
124
100%
100%
100%
92%
6
7
Inflammatory bowel disease (IBD)
Includes: Paediatric Inflammatory
Bowel Disease Services
PROMs Hernia 

Yes
Yes
126 (April &
December 2014)
110
74%
90%
8
9
National Emergency Laparotomy audit
(NELA)
National Vascular Registry (elements include NCIA, peripheral vascular surgery, VSGBI Vascular Surgery
Database, NVD)
PROMs, varicose veins
10 National head & neck cancer comparative audit (DAHNO)
11 National joint registry (NJR)





Yes
Yes
Yes
Yes
Yes
107
134 (April &
December 2014)
100
451 (April to
December 2014)
123
100%
61%
75%
94%
>90% 12 National Hip Fracture Database (part of Falls and Fragility Fractures Audit
Programme (FFFAP)
13 PROMs, knee replacements  Yes 90%
14 PROMs, hip replacements
15 Adult cardiac surgery audit (CABG & valvular surgery)


Yes
Yes
164 (April &
December 2014)
189 (April &
December 2014)
683
90%
100%
Quality Account 2014/2015
37

Audit
16 Congenital heart disease
17 Coronary angioplasty / PCI audit
18 Heart failure audit
19 Cardiac Rhythm Management
(previously: Cardiac arrhythmia audit
(HRM))
20 Acute coronary syndrome or Acute myocardial infarction (MINAP)
-Pulmonary Hypertension
21 Sentinel Stroke National Audit Project
(SSNAP) including SINAP
-Prescribing for mental health (POMH)
22 Adherence to British Society for
Clinical Neurophysiology (BSCN) and
Association of Neurophysiological
Scientists (ANS) Standards for Ulnar
Neuropathy at Elbow (UNE) testing
23 National neonatal audit programme
(NNAP)
24 National Paediatric Diabetes audit
(NPDA)
25 Childhood epilepsy (Epilepsy 12)
UCLH eligible





No

No




UCLH participation
Yes
Yes
Yes
Yes
Cases submitted
99
604
200
1159
Yes
Yes
Yes
Yes
Yes
Yes
394
N/A
570 (April to
December 2014)
N/A
20
739 (April to
December 2014)
425
-Paediatric Intensive Care (PICANet)
26 ICNARC Case Mix Programme (Critical
Care)
27 Severe Trauma (TARN)
28 Mental Health in Emergency
Departments
29 Older People (Care in Emergency
Departments)
30 Fitting Child (Care in Emergency
Departments)
31 Diabetes (Adult) ND(A), includes
National Diabetes Inpatient Audit
(NaDIA)
No






Yes
Yes
Yes
Yes
Yes
Yes
91
19
No data collection in
2014-15
Percentage of cases required
100%
100%
100%
100%
100%
58%
100%
100%
100%
27 (In conjunction with
The Royal Free
London NHS
Foundation Trust)
N/A
1760 (April to
December 2014)
180
44
100%
100%
81%
100%
100%
100%
Not applicable
38
University College London Hospitals NHS Foundation Trust

Audit
32 National Audit of Dementia
--
--
33 Rheumatoid & early inflammatory arthritis
National Chronic Kidney Disease audit
Renal Replacement Therapy
34 Adult Community Acquired
Pneumonia
35 Non-invasive Ventilation
36 COPD
37 Pleural procedures
38 National Audit of Intermediate Care
39 National Comparative Audit of Blood
Transfusion
40 National Cardiac Arrest Audit
UCLH eligible


UCLH participation
Yes
Yes
Cases submitted
Pilot site, data collection due approx. Aug-Nov
2015
50
Percentage of cases required
Not applicable
70%
No
No







Yes
Yes
Yes
Yes
Yes
Yes
Yes
N/A
N/A
Data collection in progress
(December 2014
– May 2015)
No data collection in
2014-15
60
14
50
1158
Not applicable
Not applicable
100%
100%
100%
86%
90 (April 2014 –
February 2015)
100%
NCE
National confidential enquiry into patient outcome and death
(NCEPOD)
Maternal infant and newborn programme
(MBRRACE-UK)
UCLH eligible


UCLH participation
Yes
Yes
Cases submitted
Sepsis – 5 cases (study still open)
Gastrointestinal haemorrhage – 4 cases
Perinatal death – 23 neonatal deaths and
32 pregnancy losses submitted
1 maternal death
Cases required
Sepsis: 8 cases
GI – 9 cases
100%
The reports of five national clinical audits and 11 local clinical audits were reviewed by the Trust at corporate level in 2014/15. Examples of actions University College London Hospitals NHS Foundation Trust intends to take to improve the quality of healthcare provided are shown below.
Quality Account 2014/2015
39

National Paediatric Diabetes Audit (NPDA) – The primary aim of the NPDA is to examine the quality of care in children and young people with diabetes and their outcomes. UCLH is a high performing Trust and ranks third in England and Wales. A way of monitoring blood sugar levels long term is to check how many red blood cells are carrying oxygen and glucose (these cells are called glycated).The National
Institute for Health and Care Excellence (NICE) have set a national target for the number of these cells and the NPDA monitors this. UCLH is working directly with our families to set achievable individual blood glucose targets with them to do even better than the national target which leads to better outcomes for our patients.
Pleural Procedures – This audit reviews the procedures used to drain built up fluid in the space between the lung and the chest wall (pleural space) due to various causes such as heart failure or cancer. UCLH has introduced care plans, to ensure consistent care for patients who require drainage of fluid on the lungs (pleural effusions) and for collapsed lungs
(pneumothoraces). In addition UCLH has introduced an audit of chest drainage equipment across the Trust to examine different practices, and seek opportunities to standardise and improve safety.
Paediatric Epilepsy 12 point audit – This audit was established in 2009, with the aim of helping epilepsy services to measure and improve the quality of care for children and young people with seizures and epilepsies. Key results found that only 79 per cent of children diagnosed with epilepsy had seizure classification by one year – classification improves care because it ensures the most appropriate drugs can be given. This finding of 79 per cent was not considered a problem because in some children it was difficult to classify seizures. Nevertheless it was agreed to continue to work on classification to increase the number of children with a classification. In addition
UCLH has introduced a template to be used for follow up patients in clinic to improve follow up appointments.
National Lung Cancer Audit (NLCA) – The National
Lung Cancer Audit looks at the care delivered
40
University College London Hospitals NHS Foundation Trust during referral, diagnosis, treatment and outcomes for people diagnosed with lung cancer and mesothelioma. The Trust has nationally leading rates on diagnosis and survival, but this audit highlighted that Lung Clinical Nurse Specialists (CNS) were not always present when the patient’s diagnosis was being given. The National Institute for Health and
Care Excellence (NICE) have set a national target of a CNS being present at diagnosis to improve patient experience. As a result the Trust has appointed a new
Lung CNS and reviewed how clinics run so the nurse can be present more often.
National Cardiac Arrest Audit – The aims of this national audit include improving patient outcomes as well as promoting adoption and compliance with evidence-based practice. Actions as a result of this audit include an increase in junior medical staff covering surgical wards at the weekends, as well as a weekly review of cardiac arrest investigations with the specialist team and the Risk Department. Learning has been shared through UCLH’s monthly Quality and
Safety Bulletin.
The aim of the corporate clinical audit programme is to support UCLH’s top ten objectives, provide assurance to commissioners, demonstrate compliance with recommendations from the National Institute for
Health and Care Excellence (NICE) and help manage risk. A summary of the programme is below. Although they are not clinical audits per se, patient surveys are included because they are an important part of quality improvement and the best indicator of patient experience.

Objective
Improve Patient Safety
Quality Priorities
Reduce hospital acquired infections, pressure ulcers, falls and missed medications
Develop plans to move to 24 hour /7 day working where appropriate
Improve how we share learning across UCLH from safety incidents and patient feedback.
Supporting Corporate Audit Activity
Hand Hygiene
Surgical wound infection surveillance
MRSA Bacteraemia
Adherence to surgical prophylaxis guidance
Antimicrobial Prescribing
Saving Lives Care Bundle
Clostridium Difficile Infections
NHS Safety Thermometer (pressure ulcers, falls & urinary tract infection in patients with a catheter)
VTE Risk Assessments
VTE Administrations of prophylaxis
Medication Safety
Dose Omissions
Acute Kidney Injury
Quality and timeliness of GP communications following appointments
Standards of Record Keeping
Nutrition Screening
Vital Signs
Resuscitation trolley and equipment
Cardiac arrest & PERT team calls audit
World Health Organisation (WHO) Safe
Surgery Checklist
Deliver Excellent Clinical
Outcomes
Deliver high quality patient experience and customer service excellence
Improve outcomes against
Trust-wide and specialtyspecific measures
Reduce avoidable emergency admissions
Achieve access standards and the right clinical staff across emergency pathways
Develop standards for patient experience (as customers)
Develop the Making a Difference Together programme to improve patient experience
Make it easy for patients to give us timely feedback and act on it
Outcome and safety of new interventional procedures
Readmissions reported monthly via the
Performance Pack
We have taken Quality Improvement approach to the urgent care pathway enabling us to maintain and improve performance as documented monthly in our performance reports and weekly at the urgent care transformation program.
Patient Surveys:
Inpatients
Outpatients
Cancer
Maternity
Pre and post-operative patient reported outcomes
Trustwide snapshot pain audit
Pain assessment and management
End of Life Care – AMBER care bundle
Quality Account 2014/2015
41

Local clinical audits are developed by teams and specialties in response to issues identified at a local level. They may be related to a specific procedure or equipment, patient pathway, or service. The Board attaches importance to clinical audit as a tool for improving patient care. Although there has been some improvement in audit, further progress is required. Some examples are given below.
Examples of improvement resulting from local clinical audit
Adherence to antibiotic guidelines in the Emergency
Departmen t – The Emergency Department reaudited their antibiotic prescribing in line with UCLH guidelines. There was 100% compliance to basic prescribing principles but where no specific guidelines exist for treatment in the emergency setting, 10 per cent of antibiotics prescribed were inappropriate.
The emergency department have expanded their local guidelines to include conditions increasingly presenting to the department requiring antibiotics.
Fragility fractures and referral for osteoporosis management – The aim of this audit was to assess the compliance of University College Hospital’s fracture clinic with NICE guidance on the assessment of osteoporosis risk factors in patients presenting with a fracture. Patients attending the Fracture Clinic, aged
50 and above, with fractures of the wrist, ankle or hip could potentially have osteoporosis (brittle bones).
In accordance with national guidance they will now be given a self-assessment form to complete with a patient information leaflet. If they are identified as at risk they will be referred to the Osteoporosis clinic, and their GP informed, enabling swift diagnosis and treatment before further fractures occur.
Nutrition Screening Compliance at UCLH – A snapshot audit was undertaken to ascertain if 85 per cent of patients or more are nutrition screened, ensuring patients at risk of malnutrition are identified. Key results show nutrition screening is at the 85 per cent compliance rate target. To further increase compliance a new nutrition screening tool has been introduced. This remains evidence based but is more streamlined for staff to complete, improving patient outcomes.
Epilepsy surgery evaluations – The aim of this audit
42
University College London Hospitals NHS Foundation Trust was to compare current clinical practice in regard to
Epilepsy Surgery at the Telemetry Unit with previous studies and available guidelines. 613 patients were admitted for pre-surgical evaluation over the last 5 years. As a result of the audit the Telemetry Unit at the National Hospital for Neurology and Neurosurgery
(NHNN) have begun pre-surgery counselling to advise patients of their personal risk versus the benefits and of their realistic outcomes of epilepsy surgery at the start of their surgical pathway. It is hoped that this will reduce the number of patients who decide not to go ahead with surgery in the final stages of preassessment following many hospital appointments and tests.
Audit to see whether UCLH/ NHNN brain tumour patients are following DVLA (Driver and Vehicle
Licensing Agency) guidelines – Following patients’ confusion regarding driving guidelines, patients will be given a patient information leaflet when they attend the radiotherapy department informing them of the DVLA regulations. In addition, neurosurgeons are advised to incorporate discussions about driving into the clinic letter.
A key focus for the National Institute for Health
Research is the development and delivery of quality, relevant, patient focused research within the NHS.
UCLH continues to embrace this aim, remaining at the forefront of research activity, creating and supporting research infrastructures, providing expert and prompt support in research and regulatory approvals, and promoting key academic and commercial collaborations.
UCLH continues to develop the active involvement of patients and the public in research design and process through training and other resources, to ensure those studies which take place at UCLH are relevant and inclusive of patients. UCLH will also be focusing its efforts on improving patient and public access to information about research to improve patient choice and experience.
Between April 2014 and March 2015 a total of
284 new research studies were approved to begin recruitment at UCLH. These range from Clinical Trials of Medicinal Products and Device studies, through to service and patient satisfaction studies. There are currently 1523 studies involving UCLH patients that are open to recruitment or follow-up. Of these, around 50 per cent of studies are adopted onto the
National Institute of Health Research Clinical Research

Network (NIHR CRN) portfolio of research.
The number of patients receiving relevant health services provided or sub-contracted by University
College London Hospitals NHS Foundation Trust in
2014/15 that were recruited during that period to participate in research approved by a research ethics committee was 21363.
UCLH is recognised as one of 11 leading centres for experimental medicine in England. In partnership with
University College London UCLH has secured National
Institute of Health Research Biomedical Research
Centre status for another five years (2012-17). The
Biomedical Research Centre has a focus on our four broad areas of world class strength for innovative, early phase research in cancer, neuroscience, cardiometabolic diseases and Infection, immunity and inflammation.
UCLH’s commitment to research is further evidenced by the fact it is part of UCL Partners, one of five Academic Health Science Partnerships. UCLP itself has a director of quality committed to sharing best practice across the partnership. UCLH is one of four centres pioneering a UCLP initiative to streamline the approval and successful recruitment to commercially contract clinical trials across North Thames.
Quality Account 2014/2015
43

Commissioning for Quality and Innovation (CQUIN) is a payment framework that allows commissioners to agree payments to hospitals based on agreed quality improvement and innovation work.
A proportion of University College Hospitals NHS Foundation Trust’s income in 2014/15 was conditional on achieving quality improvement and innovation goals agreed between University College Hospitals NHS
Foundation Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of relevant health services, through the Commissioning for Quality and Innovation payment framework.
Through discussions with our commissioners we agreed a number of improvement goals for 2014/15 that reflect areas of improvement interest nationally, within London and locally. The total of income conditional upon achieving quality improvement and innovation goals for 2014/15 is £14,560,023*.
The associated payment in 2013/14 was £16,025,891. A high level summary of the CQUIN measures for
2014/15 is shown in the following table:
CQUIN
National CQUIN
Local CQUIN
NHS England CQUIN
CQUIN Categories
Friends & Family Test
NHS Thermometer- Pressure ulcers
Dementia and delirium
Smoking prevention
Alcohol misuse
Domestic violence
Value based commissioning
Specialised workshops
Endocrine out-patient coding
Cardiac surgery
Specialised orthopaedics
Perinatal pathology
Retinopathy of permaturity
Clinical utilisation (Neuro rehab)
Fetal Medicine – tertiary opinion
Dashboards
QIPP scheme – PAO / JHS waiting times
QIPP scheme – MS admissions avoidance
QIPP scheme – Reducing LoS Brain Tumour surgery
Bowel cancer Screening
Smoking cessation
Actual Value
£830,690
£936,070
£991,862
£1,732,323.58
£1,645,707.40
£1,732,323.58
£906,444.74
£543,620
£557,559
£557,559
£418,170
£557,559
£418,170
£418,170
£418,170
£599,376
£362,414
£362,414
£362,414
£27,025
£9,799
Further details of the agreed goals for 2014/15 and for the following 12 month period are available on request from:
Performance Department
2nd Floor Central
250 Euston Road
London, NW1 2PG
Email: directors@uclh.nhs.uk
Phone: 020 3447 9974
* This figure is still provisional. A final figure will not be available until all activity has been billed through at the beginning of June.
44
University College London Hospitals NHS Foundation Trust

University College Hospitals NHS Foundation Trusts is required to register with the Care Quality Commission
(CQC) and its current registration status is that all Trust locations are fully registered with the CQC, without conditions.
The Care Quality Commission has not taken enforcement action against University College
Hospitals NHS Foundation Trust during the reporting period ending on 31st March 2015.
University College Hospitals NHS Foundation
Trust has not participated in any special reviews or investigations by the CQC during the reporting period.
Clinicians and managers need ready access to accurate and comprehensive data to support the delivery of high quality care. Improving the quality and reliability of information is therefore a fundamental component of quality improvement. At University
College Hospitals NHS Foundation Trust we monitor the accuracy of data in a number of ways including a monthly data quality review group, coding improvement and medical records improvement groups.
University College Hospitals NHS Foundation Trusts submitted records during 2014/15 to the Secondary
Uses service for inclusion in the Hospital Episode
Statistics which are included in the latest published data.
The percentage of records in the published data*:
which included the patient’s valid NHS number was:
 97.30 per cent for admitted patient care
 98.40 per cent for outpatient care
 81.03 per cent for accident and emergency care
which included the patient’s valid General Medical
Practice Code was:
 96.98 per cent for admitted patient care
 95.93 per cent for outpatient care
 90.22 per cent for accident and emergency care
*12 months’ worth of data is not available until 3 June
2015. The figures above are based on Months 1-11 i.e.
April 2014 to February 2015 inclusive.
The Information Governance Toolkit (IGT) provides an overall measure of the quality of data systems, standards and processes. The score a trust achieves is therefore indicative of how well they have followed guidance and good practice.
The University College London Hospitals NHS
Foundation Trust Information Governance Assessment
Report overall score for 2014/15 was 71 per cent and was graded green.
University College Hospitals NHS Foundation Trust was subject to the Payment by Results clinical coding audit during 2014/15 by the Audit Commission and the error rates reported in the latest published audit for that period for diagnoses and treatment coding (clinical coding) were:
Primary Diagnoses Incorrect = 5.5 per cent
Secondary Diagnoses Incorrect = 4.5 per cent
Primary Procedures Incorrect = 4.5 per cent
Secondary Procedures Incorrect = 3.9 per cent
Clinical coding is the process by which patient diagnosis and treatment is translated into standard, recognised codes that reflect the activity that happens to patients. The accuracy of this coding is a fundamental indicator of the accuracy of patient records. The results should not be extrapolated further than the actual sample audited.
The following services were audited:
HRG Subchapter: AA –Nervous System Procedures
& Disorders
HRG Subchapter : PA – Paediatric Medicine
University College Hospitals NHS Foundation Trust will be taking the following actions to improve data quality:
the continuation of a systematic training and audit cycle that underpins high quality coding within the Coding Department
ongoing engagement with clinicians and clinical divisions in the validation of coded activity ensuring accuracy between coding classifications and clinical care provided
an e-learning module has been introduced which has enhanced awareness of coding amongst clinicians. It covers all aspects surrounding the importance of coding and has an assessment at the end to gauge the level of understanding.
This module has been incorporated within the mandatory training profile for all doctors to ensure that it is competed by all and general managers have been driving this in their areas.
Quality Account 2014/2015
45

5
The following table provides information against a number of national priorities and measures from the UCLH
Quality & Safety scorecard we have chosen to focus on and which forms part of our continuous UCLH review and reporting. These measures cover patient safety, experience and clinical outcomes and are metrics nationally known to be important indicators in their respective areas. Where possible we have included historical performance and where available we have included national benchmarks so that progress over time can be seen as well as performance compared to other providers.
+ These indicators use nationally agreed definitions in their construction. Otherwise indicators are necessarily locally defined.
We have chosen to measure our performance against the following metrics:
Safety measures reported
1 Patients with MRSA infection/10,000 bed days+
2 Patients with Clostridium difficile infection/10,000 bed days+
3 Medication incidents
2012/13
0.23
2.05
1112
2013/14
0.22
3.71~
1435
2014/15
0.11
4.04
1366
2014/15 benchmark
0.1
1.3
What this means
Lower scores are better
Lower scores are better. **
No local target
4 Inpatient falls with harm * ¯
5 CVC (see glossary) line care
6 Safe surgery intervention (time out using WHO safety checklist)
7 Vital signs audit (Harm from deterioration) ¨
8 Surgical site infections +
Clinical outcome measures reported
9 External Summary Hospital-level
Mortality Indicator (SHMI) – Rolling one year period, six months in arrears+
10 Stroke mortality rates (Based on diagnoses 161x, 164x, P101, P524)
11 Deaths in hospital
145 136 297 187
93.50% 95.13% 89.49% No local target
91.00% 89% 95% No local target
91.40% 92.43%^ 95.68% 95%
7.10%
68
8.93%
822
0.94%
8.30%
75
9.29%
924
0.71%
6.88%
79.5
7.87%
892
0.52%
0.00%
100
No local target
No local target
0.80% 12 Last minute cancelled operations *+
13 28 day Emergency Readmission rate + (readmissions to UCLH)
3.00% 2.80%
136
2.90%
158
6% (chks peer Apr
13to Mar 14)
144 14 Complication following surgery
*
127
Patient Experience Measures Reported
15 Overall satisfaction rating + 8.3
16 Respect and dignity +
17 Involvement in decisions +
18 Worries and fears +
Staff Experience Measures Reported
19 Staff job satisfaction +
9.1
7.1
5.9
3.62
8.3
9.1
7.2
5.9
3.64
8.1
8.8
7.5
5.8
3.61
3.6
Higher numbers may indicate a more open reporting culture
Lower scores are better
Higher scores are better
Higher scores are better
Higher scores are better
Lower scores are better.
NHS Choices website.
Summary Hospital-level
Mortality Indicator (SHMI),
Lower scores are better
Lower scores are better.
Lower numbers are better.
Lower scores are better.
Lower numbers are better
Lower numbers are better
Higher numbers are better
Higher numbers are better
Higher numbers are better
Higher numbers are better
Higher numbers are better
46
University College London Hospitals NHS Foundation Trust

We have chosen to measure our performance against the following metrics:
2012/13
20 Appraisal & re-validation rates + 86%
21 Care of patients is my Trust’s top priority +
79%
3.99
22 Staff would recommend the
Trust as a place to work +
23 If a friend or relative needed treatment, I would be happy with the standard of care provided by this Trust +
83%
2013/14
93%
84%
4.05
83%
2014/15
91%
81%
3.98
83%
2014/15 benchmark
85%
70%
3.67
65%
What this means
Higher numbers are better
Higher numbers are better
Higher numbers are better
Higher numbers are better
**The C difficile figure is the total number of trust attributable cases which includes successful appeals, cases under review and lapses in care
+ These indicators use nationally agreed definitions in their construction. Otherwise indicators are necessarily locally defined.
~This was reported as 3.66 in last year’s Quality account as the data had not been finalised
*14/15 Local targets used as 14/15 benchmark figure
^ This was reported as 91.87 in last year’s account but the figure has since been updated.
¯Falls reporting has been replaced with inpatient falls with harm since 2011-12. The methodology for counting falls has changed in 2014-15, with unwitnessed falls now being included.
¨ The value stated uses the reporting of 8 vital signs using the Meridian App which commenced in mid-May therefore the data only represents the time period from May-March. Prior to this measurements were against only 6 vital signs.
Three indicators that are no longer measured have been removed – percentage of all inpatients screened for
MRSA, nurses and doctors working together, patient would recommend hospital to family/friends.
Monitor uses a limited set of national measures of access and outcome objectives as part of the assessment of governance at NHS foundation trusts. It is a Monitor requirement to include these in the UCLH Quality account.
The table below sets out the measures, thresholds and quarterly performance.
Threshold Q1 Q2 Q3 Q4
2014-15 actual
Indicator
Access
Referral to treatment time, 18 weeks in aggregate, admitted patients*
Referral to treatment time, 18 weeks in aggregate, non-admitted patients*
Referral to treatment time, 18 weeks in aggregate, incomplete pathways*
A&E Clinical Quality- Total Time in A&E under 4 hours
Cancer 62 Day Waits for first treatment
(from urgent GP referral)
90%
95%
92%
95%
85%
83.7%
93.2%
87.2%
95.0%
75.2%
83.0%
92.8%
87.9%
94.2%
67.1%
80.8%
88.8%
90.9%
94.1%
66.9%
83.1%
95.1%
93.3%
95.1%
69.5%
82.7%
92.6%
89.7%
94.6%
69.7%
Quality Account 2014/2015
47

Indicator
Cancer 62 Day Waits for first treatment
(from NHS Cancer Screening Service referral)
Cancer 31 day wait for second or subsequent treatment – surgery
Cancer 31 day wait for second or subsequent treatment – drug treatments
Cancer 31 day wait for second or subsequent treatment – radiotherapy
Cancer 31 day wait from diagnosis to first treatment
Cancer 2 week (all cancers)
Cancer 2 week (breast symptoms)
Threshold Q1
90%
94%
98%
94%
96%
93%
93%
Q2 Q3
100.0% 100.0% 71.4%
97.3%
99.7%
99.0%
97.2%
94.3%
97.1%
96.7%
100.0%
100.0%
95.4%
93.1%
93.7%
96.0%
99.6%
100.0%
95.6%
93.2%
84.6%
Q4
80.0%
92.2%
99.7%
98.0%
91.4%
94.2%
95.0%
2014-15 actual
82.3%
95.8%
99.7%
99.6%
94.6%
93.7%
92.6%
Outcomes
C.difficile
due to lapses in care (ytd)
Total C.difficile
YTD (including: cases deemed not to be due to lapse in care and cases under review)
C.difficile
cases under review (YTD)
Total C.difficile
71 3
21
3
57
5
77
8
80
8
80
3 0 2 21 21
109
* As a result of extensive validation carried out during 2014/15, the Trust is aware that its historic RTT performance figures did not contain all pathways that at the time fell under the scope of the RTT. The performance figures also included patient pathways where the patient was no longer waiting for treatment.
An internal audit in 2014 on RTT data quality, together with a range of other RTT data quality assessments, found clinical and administrative data entry errors and processing weaknesses in the management of RTT pathways. To address these points we have introduced and continue to develop:
improved operational reports that help clinical teams closely manage waiting lists
operational meetings at all levels of the organisation to ensure that waiting lists are scrutinised at least weekly
a more comprehensive suite of data quality accounts, including identification of where errors occurred, to help operational teams pinpoint issues and provide training for staff in how to avoid the data quality issues in the future
more support for clinicians in filling out the clinic outcome forms that are key in moving patients accurately along RTT pathways
higher quality training courses, including on RTT rules and how to manage patient waiting times records on our patient administration system
more rigorous chasing of referring hospitals for the date that patients started waiting prior to being referred on to us for treatment
technical adjustments to how we process RTT pathways through our IT systems
48
University College London Hospitals NHS Foundation Trust

Amended regulations from the Department of Health require trusts to report performance against a core set of indicators using data made available to the trust by the Health and Social Care Information Centre (HSCIC).
These mandated indicators are set out below and are as at the time of this report and may not reflect the current position. Where the required data is made available by the HSCIC, a comparison has been made with the national average results and the highest and lowest trusts’ results.
UCLH NHS Foundation Trust considers that this data is as described for the following reasons: UCLH has a robust process for clinical coding and review of mortality data so is confident that the data is accurate.
UCLH
Performance
Jul12 to
Jun13
UCLH
Performance
Jul 2013 to Jun14
UCLH
Performance
Oct 2013 to Sept
14
National
Average
Oct 13 to
Sept 14
Highest
Performing Trust
Oct 13 to
Sept 14
Lowest
Performing Trust
Oct 13 to
Sept 14 a) The value and banding of the summary hospital-level mortality indicator (‘SHMI’) for the trust for the reporting period
(b) The percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the trust for the reporting period.
73.5
(Band 3)
29.7%
78.8
(Band
3)
31.3%
79.5
(Band
3)
31.5%
100
25.4%
59.7
(Band 3)
0.0%
119.8
(Band 1)
49.4%
UCLH NHS Foundation Trust has taken the following action to improve this number and so the quality of its services:
Monthly review of specialty level mortality at local and UCLH level
patient level clinical and coding review of any specialty or conditions which show as mortality outliers when compared with national data
presenting a monthly report to the Quality and Safety Committee detailing the percentage of patient deaths with palliative care coding. UCLH has also set a local target to monitor its rate of palliative care coding and any large variances are investigated by the clinical coding team.
Quality Account 2014/2015
49

UCLH NHS Foundation Trust considers that this data is as described for the following reasons: UCLH has processes in place to ensure that relevant patients are given questionnaires to complete. However, it has no control over their completion and return.
The trust’s patient reported outcome measures scores for:
UCLH
Performance
2011/12
UCLH
Performance
2012/13
UCLH
Performance
2013/14
National
Average
2013/14
Lowest
Performing
Trust
2013/14
Highest
Performing
Trust
2013/14
0.07
0.04
0.05
0.08
0.04
0.13
(i) groin hernia surgery
(ii) varicose vein surgery
(iii) hip replacement surgery and
(iv) knee replacement surgery
0.08
0.40
0.24
0.07
0.44
0.31
0.09
0.44
0.24
0.09
0.43
0.32
0.02
0.33
0.21
0.15
0.49
0.40
UCLH NHS Foundation Trust has taken the following actions to improve this rate and so the quality of its services:
The PROMs Steering Group, chaired by a consultant lead and with consultant representatives from all relevant specialties, continues to monitor performance and agree actions with appropriate specialties.
Developed practice in knee replacement to include better pre-operative information, improved perioperative analgesia and post discharge telephone call / advice from clinical nurse practitioners.
UCLH NHS Foundation Trust considers that this data is as described for the following reasons: UCLH has a robust process for clinical coding so is confident that the data is accurate.
The percentage of patients aged:
(i) 0 to 15
(ii) 16 or over
UCLH
Performance
2009/2010
UCLH
Performance
2010/2011
UCLH
Performance
2011/12
6.69
10.65
8.12
10.73
6.32
11.72
National
Average
Amongst our Peers
2011/12*
9.49
11.31
Lowest
Performing
Trust
2011/12
14.94
17.15
Highest
Performing
Trust
2011/12
3.75
6.48
Readmitted to a hospital which forms part of the trust within 28 days of being discharged from a hospital which forms part of the trust during the reporting period.
*National Average taken against all acute trusts. Trusts with zero readmissions have been excluded from the table.
UCLH NHS Foundation Trust has taken the following actions to improve this rate and so the quality of its services:
Collaborative working with primary care and other secondary care providers across patient pathways providing physicians for community clinics
increasing specialist nurse discharge support to 7 day working
admissions avoidance – providing a team in the Emergency Department and Acute Medical Unit for the avoidance of preventable or inappropriate admission of patients to hospital
50
University College London Hospitals NHS Foundation Trust

enhanced social work provision strengthening joined up care
Improved information management – It is envisaged that better information across community, social, primary and secondary care will support the prevention of unnecessary re admissions
specialist nurse discharge support – UCLH will continue to enhance the skills of its established discharge and admission avoidance team to optimise patient care across organisational boundaries.
UCLH NHS Foundation Trust considers that this data is as described for the following reasons: undertaken independently as part of the annual national inpatient survey.
UCLH
Performance
2012/13
71.9
UCLH
Performance
2013/14
68.9
National
Average
2013/14
Lowest
Performing Trust
2013/14
54.5
Highest
Performing Trust
2013/14
84.2
The trust’s responsiveness to the personal needs of its patients during the reporting period.
68.7
UCLH NHS Foundation Trust has taken the following actions to improve this rate and so the quality of its services:
Monitoring performance on Meridian in real-time through regular discussion at quality huddles and agreeing local action plans
Trialled new patient information card explaining other staff that patients could talk to
Added another field to Meridian ‘did the nurse in charge introduce herself every shift?’
* Responsiveness to personal needs of patients is a composite score from five CQC National Inpatient Survey questions. The five questions are:
Were you as involved as you wanted to be in decisions about your care and treatment?
Did you find someone on the hospital staff to talk to about worries and fears?
Were you given enough privacy when discussing your condition or treatment?
Did a member of staff tell you about medication side effects to watch for when you went home?
Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital?
UCLH NHS Foundation Trust considers that this data is as described for the following reasons: undertaken independently as part of the annual national staff survey.
UCLH
Performance
2013/14
UCLH
Performance
2014/15
National
Average of
Acute Trusts
2014/15
Lowest
Perfor-ming
Acute Trust
2014/15
Highest
Perfor-ming
Acute Trust
2014/15
The percentage of staff employed by, or undercontract to, the trust during the reporting period who would recommend the trust as a provider of care to their family or friends.
83.4% 83.5% 64.7% 38.2% 89.3%
UCLH NHS Foundation Trust has taken the following actions to improve this rate and so the quality of its services:
Staff suggestion scheme launched in Sept 2014 which includes suggestions to improve both staff and
Quality Account 2014/2015
51

patient experience
Further actions that will be taken include:
New focus on staff experience will be launched in April 2015
Further work to look at common themes arising from both patient and staff issues and identify actions to address
Other areas are as described in the patient experience priority
UCLH NHS Foundation Trust considers that this data is as described for the following reasons: the Trust has a robust process for measuring VTE risk assessment of patients and this is also part of the monthly Safety
Thermometer audit.
UCLH
Performance July
2014 to
Sep 2014
UCLH
Performance Oct
2014 to Dec
2014
National
Average Oct
2014 to Dec
2014
Lowest
Performing
Trust Oct
2014 to Dec
2014
Highest
Performing
Trust Oct
2014 to Dec
2014
The percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period.
94.4% 93.3% 95.9
81.2
100
UCLH NHS Foundation Trust has taken the following actions to improve this rate and so the quality of its services:
Monitoring as part of the Key Performance Indicators from ward up to Board level
Identifying and taking action in low performing areas
UCLH NHS Foundation Trust considers that this data is as described for the following reasons: the data has been sourced from the Health and Social Care Information Centre and compared to internal UCLH data and data hosted by the Health Protection Agency.
UCLH
Performance
2012/13
20.50
UCLH
Performance
2013/14
37.1
National
Average
2013/14
Lowest
Performing
Trust 2013/14
Highest
Performing
Trust 2013/14
The rate per 100,000 bed days of cases of C.difficile infection reported within the trust amongst patients aged 2 or over during the reporting period.
14.7
37.1
0
This refers to all UCLH attributable c difficile infections including those subsequently appealed and under review.
UCLH NHS Foundation Trust has taken the following actions to improve this rate and so the quality of its services:
Comprehensive action plan focusing on standardising cleaning practice across our sites, improving hand hygiene for everyone entering the hospital, and improving our learning from any Clostridium difficile cases.
Implemented an upgraded deep-clean regime and the use of hydrogen peroxide vapour cleaning.
Continue to monitor antibiotic prescribing
52
University College London Hospitals NHS Foundation Trust

UCLH NHS Foundation Trust considers that this data is as described for the following reasons: data has been submitted to the National
Reporting and Learning System (NRLS) in accordance with national reporting requirements.
UCLH
Performance
October
2012 –
March 2013
UCLH
Performance
October
2013 –
March 2014
National
Average
October
2013 –
March 2014
3660 3785 6184 The number of patient safety incidents reported within the trust during the reporting period.
The rate of patient safety incidents reported within the trust during the reporting period.
The number of such patient safety incidents that resulted in severe harm or death.
The percentage of such patient safety incidents that resulted in severe harm or death.
5.7
21
0.6%
4.7
14
0.4%
8.7
22.8
0.4%
UCLH NHS Foundation Trust has taken the following actions to improve this rate and so the quality of its services:
Encourage incident reporting through the monthly Quality and Safety bulletin which shares learning on reporting from incidents, and encourages the reporting of near misses.
Introduced a quarterly report on incident trends and learning
Correction:
With apologies to Central Manchester University Hospitals, in last year’s Quality account we reported that they had the worst incident reporting rate. They actually had the best incident reporting rate as a higher rate is better.
Lowest
Performing
Trust
October
2013 –
March 2014
2422
4.6
69
1.00%
Highest
Performing
Trust
October
2013 – March
2014
12152
14.9
1
0.00%
Quality Account 2014/2015
53

NHS Camden Clinical Commissioning Group (CCG) is responsible for the commissioning of health services from University College London Hospitals (UCLH)
NHS Foundation Trust on behalf of the population of Camden and surrounding boroughs. NHS Camden
CCG have worked closely with UCLH to ensure we have the right level of assurance in relation to these commissioned services and we have undertaken commissioner walk rounds in UCLH and formally review service quality at the Clinical Quality Review
Groups.
NHS Camden Clinical Commissioning Group welcomes the opportunity to provide this statement on UCLH’s Trust’s Quality Accounts. We confirm that we have reviewed the information contained within the Account and checked this against data sources where this is available to us as part of existing contract/performance monitoring discussions and is accurate in relation to the services provided. We have taken particular account of the identified priorities for improvement for UCLH Trust and how this work will enable real focus on improving the quality and safety of health services for the population they serve.
We have reviewed the content of the Account and confirm that this complies with the prescribed information, form and content as set out by the
Department of Health. We believe that the Account represents a fair, representative and balanced overview of the quality of care at UCLH. We have discussed the development of this Quality Account with UCLH over the year and have been able to contribute our views on consultation and content.
This Account has been shared with NHS Islington,
NHS Central London CCGs, NHS Haringey, NHS Enfield and NHS Barnet Clinical Commissioning Groups, NHS
England and by colleagues in NHS North and East
London Commissioning Support Unit for their review and input.
We are pleased to see the UCLH’s chosen priority areas for improvement and ambition to focus on quality and safety to be further embedded in 2015/16.
The emphasis for improvement in the use of the
World Health Organization (WHO) Surgical Safety
Checklist and the focus on improving Cancer patient experience is welcomed.
UCLH is extending the focus on prioritising Trust wide learning from Serious Incidents in 2015/16 and it is pleasing to see that this area continues to be a priority for the Trust. In particular the approach to learning from Never Events and achieving the national guidelines for investigation reports being completed following a serious incident (60 working days) will further embed the patient safety culture within the Trust. As a CCG we will continue to monitor this area moving forward and acknowledge the improvements they have achieved to date.
Within this Account UCLH acknowledges challenges faced in reducing patient treatment waiting times. In 2015/16 we would like to see further improvements made in reducing patient treatment waiting times, with a focus on improving patient safety, experience and clinical effectiveness. We would also envisage improvements in other areas of patient experience in relation to maternity services, and privacy and dignity of inpatients.
Overall this is a very positive Quality Account and we welcome the vision described and agree on the priority areas. There are still areas for improvements to be made and as commissioners NHS Camden CCG will continue to work with UCLH continuously and monitor these areas to improve the quality of services provided to patients.
NHS Camden Clinical Commissioning Group
Camden Healthwatch and the Camden Health and
Adult Social Care Scrutiny welcome the opportunity to jointly comment on University College London
Hospitals NHS Foundation Trusts’ (UCLH) Quality
Account for 2014/15 and their priorities for quality improvements in 2015/16.
It is clear from the report that the Trust has performed well this year in what has been a challenging climate for the NHS and for this it is to be congratulated. There is evidence of progress being made on waiting time targets for both cancer and referral to treatment waits and the Trust also met the A&E target of 95% of patients seen within
4 hours during the difficult winter period which is a considerable achievement. There is still room for improvement however in meeting waiting time targets for A&E and we would like the Trust to say more about how it is working with partners locally to reduce attendances at A&E.
We are pleased with the way the Trust has responded to the findings of the CQC inspection in
November 2013 although recognising there is work still to be done. We are pleased that outpatient experience will continue to be a priority for the Trust in the coming year.
We believe that there is still room for improvement with the quality account in terms of tailoring the content and style of the report for a public readership and we would like the Trust to do
54
University College London Hospitals NHS Foundation Trust

more to explain in future reports how it has engaged with the public, patients and governors in setting its priorities. We would also like to see the Trust say more about what it offers to the community in its immediate environment.
Overall, this is a very encouraging report, representing a huge amount of work and effort by the staff. As always there is a lot left to do but the people of Camden who use this hospital should feel reassured.
Quality Account 2014/2015
55

The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts)
Regulations to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support the data quality for the preparation of the quality report.
In preparing the Quality Report, directors are required to take steps to satisfy themselves that:
the content of the Quality Report meets the requirements set out in the NHS Foundation Trust
Annual Reporting Manual 2014/15 and supporting guidance
the content of the Quality Report is not inconsistent with internal and external sources of information including:
Board minutes and papers for the period April
2014 to 21/05/2015;
Papers relating to Quality reported to the
Board over the period April 2014 to 21/05/2015
Feedback from the commissioners dated
30/04/2015
Feedback from the governors between
01/01/2015 and 31/04/2015
Feedback from Local Healthwatch organisations dated 11/05/2015
Feedback from Overview and Scrutiny
Committee dated 11/05/2015
The trust’s complaints report published under regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009, dated 01/04/2013 to 31/03/2014 and quarterly reports during the year
National patient survey 21/05/2015
National staff survey 24/02/2015
The head of internal audit’s opinion over the trust’s control environment dated 11/05/2015
Care Quality Commission intelligent monitoring reports between 01/04/2014 and
31/12/2014
the Quality Report presents a balanced picture of the NHS foundation trust’s performance over the period covered;
the performance information reported in the
Quality Report is reliable and accurate;
there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice;
the data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and
the Quality Report has been prepared in accordance with Monitor’s annual reporting guidance (which incorporates the Quality
Accounts regulations) (published at www.
monitor.go.uk/annualreportingmanual) as well as the standards to support data quality for the preparation of the Quality Report (available at www.monitor.gov.uk/annualreportingmanual).
The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report.
By order of the Board
NB: sign and date in any colour ink except black
27 May 2015
27 May 2015
56
University College London Hospitals NHS Foundation Trust

We have been engaged by the council of governors of University College London Hospitals NHS
Foundation Trust to perform an independent assurance engagement in respect of University College London
Hospitals NHS Foundation Trust’s quality report for the year ended 31 March 2015 (the ‘Quality Report’) and certain performance indicators contained therein.
This report, including the conclusion, has been prepared solely for the council of governors of
University College London Hospitals NHS Foundation
Trust as a body, to assist the council of governors in reporting University College London Hospitals NHS
Foundation Trust’s quality agenda, performance and activities. We permit the disclosure of this report within the Annual Report for the year ended 31 March 2015, to enable the council of governors to demonstrate they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Council of
Governors as a body and University College London
Hospitals NHS Foundation Trust for our work or this report, except where terms are expressly agreed and with our prior consent in writing.
The indicators for the year ended 31 March 2015 subject to limited assurance consist of the national priority indicators as mandated by Monitor:
Cancer 62 day waits for first treatment (from urgent GP referral); and
Referral to treatment time, 18 weeks in aggregate, incomplete pathways.
the quality report is not consistent in all material respects with the sources specified in the Detailed guidance for external assurance on quality reports, issued by Monitor; and
the indicators in the quality report identified as having been the subject of limited assurance in the quality report are not reasonably stated in all material respects in accordance with the ‘NHS foundation trust annual reporting manual’ and the six dimensions of data quality set out in the
‘Detailed guidance for external assurance on quality reports’.
We read the quality report and consider whether it addresses the content requirements of the ‘NHS foundation trust annual reporting manual, and consider the implications for our report if we become aware of any material omissions.
We read the other information contained in the quality report and consider whether it is materially inconsistent with:
board minutes for the period April 2014 to 27 May
2015;
papers relating to quality reported to the board over the period April 2014 to 27 May 2015;
feedback from Camden Clinical Commissioning
Group, dated 30/04/2015;
feedback from governors, dated between
01/01/2015 and 30/04/2015;
feedback from local Healthwatch organisations, dated 11/05/2015;
feedback from Overview and Scrutiny Committee, dated 11/05/2015;
the trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated
01/04/2013 to 31/03/2014;
the national patient survey, dated 21/05/2015;
the national staff survey, dated 24/02/2015;
Care Quality Commission Intelligent Monitoring
Report dated 01/12/2014 and 01/07/2014;
the Head of Internal Audit’s annual opinion over the trust’s control environment dated 13/05/2015; and
any other information included in our review.
We refer to these national priority indicators collectively as the ‘indicators’.
The directors are responsible for the content and the preparation of the quality report in accordance with the criteria set out in the ‘NHS foundation trust annual reporting manual’ issued by Monitor.
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that:
the quality report is not prepared in all material respects in line with the criteria set out in the ‘NHS foundation trust annual reporting manual’;
We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with those documents
(collectively the ‘documents’). Our responsibilities do not extend to any other information.
We are in compliance with the applicable independence and competency requirements of the
Institute of Chartered Accountants in England and
Wales (ICAEW) Code of Ethics. Our team comprised
Quality Account 2014/2015
57

assurance practitioners and relevant subject matter experts.
We conducted this limited assurance engagement in accordance with International Standard on Assurance
Engagements 3000 (Revised) – ‘Assurance Engagements other than Audits or Reviews of Historical Financial
Information’ issued by the International Auditing and
Assurance Standards Board (‘ISAE 3000’). Our limited assurance procedures included:
evaluating the design and implementation of the key processes and controls for managing and reporting the indicators;
making enquiries of management;
testing key management controls;
analytical procedures to include re-performance of calculations;
limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation;
comparing the content requirements of the ‘NHS foundation trust annual reporting manual’ to the categories reported in the quality report; and
reading the documents.
A limited assurance engagement is smaller in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement.
Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information.
The absence of a significant body of established practice on which to draw allows for the selection of different, but acceptable measurement techniques which can result in materially different measurements and can affect comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision of these criteria, may change over time. It is important to read the quality report in the context of the criteria set out in the ‘NHS foundation trust annual reporting manual’.
The scope of our assurance work has not included testing of indicators other than the two selected mandated indicators, or consideration of quality governance.
As set out in the Review of Quality Performance section on page 138 of the Trust’s Quality Report, the Trust identified a number of issues in its 18 week
Referral-to-Treatment reporting during the year that was supported by our testing, including:
The published indicator incorrectly includes records which should be excluded from the calculation;
The underlying data includes records where end dates of treatment were not captured, per the national guidelines and the Trust’s access policy, affecting the calculation of the published indicator; and
The calculation of the published indicator has been applied on an incorrect date.
With support from NHS England’s Intensive Support
Team, the Trust has taken actions to resolve the issues identified in its processes and is due to complete its planned responses in June 2015. As the Trust notes, the data prior to this date has not been revised and the resulting metrics have not been recalculated as it is not practical to do so.
As a result of the issues identified by the Trust in the data we have concluded that there are errors in the calculation of the 18 week Referral-to-Treatment incomplete pathway indicator for the year ended 31
March 2015.
We are unable to quantify the effect of these errors on the reported indicator for the year ended 31 March
2015.
Based on the results of our procedures, except for the effect of the matters set out in the basis for qualified conclusion paragraph, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2015:
the quality report is not prepared in all material respects in line with the criteria set out in the NHS
Foundation Trust Annual Reporting Manual;
the quality report is not consistent in all material respects with the sources specified in Monitor’s
Detailed Guidance for External Assurance on
Quality Reports 2014/15; and
the indicators in the quality report subject to limited assurance have not been reasonably stated in all material respects in accordance with the NHS
Foundation Trust Annual Reporting Manual.
27 May 2015
58
University College London Hospitals NHS Foundation Trust

AMBER Care Bundle – AMBER Care Bundle provides a systematic approach to improve the care of hospital patients who are facing an uncertain recovery with limited reversibility and who are at risk of dying in the next one to two months. It consists of four elements:
talking to the person and their family to let them know that the healthcare team has concerns about their condition, and to establish their preferences and wishes
deciding together how the person will be cared for should their condition get worse
documenting a medical plan
agreeing these plans with all of the clinical team looking after the person.
Cancer survey – calculation of responses – the questions are summarised as the percentage of patients who reported a positive experience.
Neutral responses, such as “Don’t Know” and ‘I did not need an explanation’ are not included in the denominator when computing the score.
The higher the score the better the UCLH’s performance.
Care bundles – consist of a group of precautionary steps which, when combined and executed reliably for a specific treatment, have proven to significantly reduce untoward outcomes.
Care Quality Commission (CQC) – the independent regulator of all health and social care services in
England
CNS – clinical nurse specialist
Commissioners – the organisation, NHS North
Central London, that commissions care for UCLH patients
CQC Inpatient Survey – Scoring – For each question in the survey, the individual
(standardised) responses are converted into scores on a scale from 0 to 10. A score of 10 represents the best possible response and a score of zero the worst. The higher the score for each question, the better the trust is performing.
CQUIN – Commissioning for Quality and
Innovation – is a payment framework which allows commissioners to agree payments to hospitals based on agreed improvement work
In addition to contributing to the UCLH wide programmes, local teams routinely identify their own quality improvement topics in areas that they want to enhance the safety, experience or clinical outcomes of their specific patient community. In this way the ethos of continuous improvement is embedded within UCLH and is personal and proactive.
CVC – central venous catheters. A catheter placed into a large vein in the neck, chest or groin.
E- learning – the use of electronic educational technology in teaching and learning.
Faecal transplant – the process of transplantation of feacal bacteria from a healthy individual into a recipient. It involves restoration of the colonic microflora by introducing healthy bacterial flora through infusion of stool, e.g. by enema, orogastric tube or orally in the form of a capsule containing freeze-dried material, obtained from a healthy donor. A limited number of studies have shown it to be an effective treatment for patients suffering from Clostridium difficile infection.
Governors – staff representatives on the Council of Governors (previously Governing Body), which helps to shape the services UCLH provides and reflects the needs and priorities of patients, staff and local communities.
Improving Care Rounds – At UCLH we undertake
‘Improving Care walk rounds’ to help staff and management teams to prepare for regulatory inspections by the Care Quality Commission
(CQC). According to the model recommended by Sir Bruce Keogh, the Medical Director of the
National Health Service in England, the walk rounds are multidisciplinary. Our walk round team includes junior and senior medical staff, student nurses, senior nurses, managers, AHPs, patients by experience and specialists in medication safety, infection control and safeguarding. The purpose of the walk rounds is not to criticise, but to promote improvement in care, environment and services by coming into the area with ‘fresh eyes’.
Matron quality rounds – UCLH Matrons perform weekly ‘Matrons Rounds’ – these are quality, environmental & patient/staff experience reviews by groups of UCLH Matrons, outside of their own clinical areas. The Rounds provide peer review, challenge and support to clinical areas across UCLH. Feedback is instant, via a ‘huddle’.
The Rounds have been well received by staff throughout UCLH and will continue to evolve in
2015/16.
Meridian Survey – calculation of scores Meridian starts scoring at question level and builds up an overall score from each response received from patients. Meridian calculates the score based on the following steps:
What is the MAXIMUM POSSIBLE score for this question?
What is the ACTUAL score for this question?
The OVERALL score is ACTUAL / MAXIMUM.
Quality Account 2014/2015
59

Never Event – ‘Never events’ are largely preventable patient safety incidents that have the potential for, or cause severe harm, and should not occur if relevant preventative measures have been put in place.
NHSLA – National Health Service Litigation
Authority. Organisation responsible for assessing how effectively trusts manage risk.
Ombudsman – the Parliamentary and Health
Services Ombudsman consider complaints that government departments, a range of other public bodies in the UK, and the NHS in England, have not acted properly or fairly or have provided a poor service.
Picker survey – calculation of response rates and explanation of problem scores.The problem score shows the percentage of patients for each question who, by their response, indicated that a particular aspect of their care could have been improved. Problem scores are calculated by combining response categories. Lower scores are better.
Proton-pump inhibitors – a group of drugs whose main action is a pronounced and long-lasting reduction of gastric acid production. They are the most potent inhibitors of acid secretion available.
Root Cause Analysis (RCA) – Root Cause Analysis investigation is a well recognised way of identifying how and why patient safety incidents happen. Analysis is used to identify areas for change and to develop recommendations which deliver safer care for patients.
Sage and Thyme Training – a 3hr training session that teaches: a memorable structured approach for getting into and out of a conversation, how to empower patients and carers who are worried or distressed and communication skills that are evidence based
Sign up to Safety – Sign up to Safety is a new national patient safety campaign that was announced in March by the Secretary of State for Health. It launched on 24 June 2014 with the mission to strengthen patient safety in the
NHS and make it the safest healthcare system in the world. Organisations who Sign up to Safety commit to strengthen patient safety by:
Setting out the actions they will undertake in response to the five Sign up to Safety pledges and agree to publish this on their website for staff, patients and the public to see.
Committing to turn their actions into a safety improvement plan (including a driver diagram) which will show how organisations intend to save lives and reduce harm for patients over
60
University College London Hospitals NHS Foundation Trust the next 3 years.
SOAPIER – documentation tool:
SUBJECTIVE - What does the patient (and family) report as their main problems or concerns?
OBJECTIVE – Observations – Record of relevant factual measurable data (e.g. vital signs, fluid balance charts, test results…)
ANALYSIS – Conclusions or diagnosis based on subjective and objective data including risk factors.
PLAN – What are the key care requirements or outstanding issues to be addressed? To be agreed with patient and/or relatives. Details to be taken from the care plan if required.
INTERVENTION/EVALUATION – What have you done for your patient? What was the outcome of your plan?
RE-PLAN – What are the key care requirements to hand over to the next shift?
SSI – surgical site infections
VoiceAbility – VoiceAbility offer services across the advocacy and involvement spectrum. They work in many local authorities, offering statutory and informal advocacy, as well as nationwide for their consultancy, training and easyread services.
VoiceAbility runs NHS Complaints Advocacy services in several areas across England.
VTE – venous thromboembolism (blood clots)
Welcome Pack – all inpatients admitted to UCLH are given a welcome pack when they arrive on the ward. The contents of the pack and the welcome booklet have been developed to respond to patient feedback about what would make a hospital stay that bit better.
WHO Surgical Safety Checklist – The checklist identifies three phases of an operation, each corresponding to a specific period in the normal flow of work: Before the induction of anaesthesia
(“sign in”), before the incision of the skin (“time out”) and before the patient leaves the operating room (“sign out”). In each phase, a checklist coordinator must confirm that the surgery team has completed the listed tasks before it proceeds with the operation.