Quality Report
2014/15
FINAL
Date 30 May 2015
1
Contents
Quality Report 2014/15..............................................1
Part 1:
Statement on quality from the Chief
Executive ....................................................................3
Part 2:
Priorities for Improvement in 2015/16
and Board Statements of Assurance .....................10
Priorities for improvement in 2015/16 ......................10
Review against 2014/15 quality priorities ................38
Other achievements and improvements we made
in 2014/15................................................................61
Mandated performance indicators 2014/15 .............72
Annex 1: Statements from commissioners, local
Healthwatch organisations and Overview and
Scrutiny Committees ...............................................81
Annex
2:
Limited
assurance
by
external
auditors.....................................................................88
Annex
3:
Statement
of
directors’
responsibilities for the quality report.....................91
92
2
Accounts
Part 1: Statement on quality from the Chief
Executive
achieved in quality improvement over the
last year and what the Trust intends to
concentrate on during the coming year.
We have made good progress in developing
our “Improvement Programme” and driving
forward priority improvements; we have
redesigned
our
Quality
Governance
structure and embedded improvement in
our structures and processes.
Delivering high quality patient care is the
guiding principle of the Royal Berkshire
NHS Foundation Trust. Our purpose is to
serve our patients and service users; we
can only achieve this by ensuring that the
patient comes first in everything that we do.
We have prioritised patient safety and
endeavour to support this through delivering
effective outcomes and a positive patient
experience. I want to thank our staff who
constantly strive to deliver high quality care
and provide a positive experience for
patients and their carers/families.
The Quality Account (also known as the
Quality Report) provides us an opportunity
to inform the public or what we have
We have made a number of significant
achievements this year, including keeping
patients safe from Clostridium Difficile
infections, improving harm free care,
reducing weekend mortality, improvements
in medical records and improved processes
in place for handling complaints received
relating to staff behavior and attitude.
Despite a good start to the year in reducing
cancellation operations we were not able to
sustain this progress due to winter
pressures. We continue with our nursing
recruitment campaign and complete nursing
skill mix reviews biannually to ensure we
get our staffing levels right for the for the
patients we look after. We have continued
to work to ‘revalidate’ our Doctors to ensure
that they are up to date and fit to practice.
Some
highlights
of
our
quality
improvements achievements in 21014/2015
are:
Being recognised as one of the best places
to work by the Health Service Journal.
Welcoming 15 patient leaders who
are working in partnership with us to
improve
services
across
the
organisation.
3
The launch of the “#hello my name”
a
campaign
to
enhance
compassionate care.
An award winning Cardiology Team
Research & Development
have
made a significant contribution
towards enhancing patient care
including
avoiding
emergency
admissions for older people, the
management of pain in the
Emergency
Department,
and
evaluating a new blood test for
earlier detection of acute kidney
injury.
During 2014/15 we have been subject to
enforcement action from Monitor, the
regulator of the NHS with respect to our 18
week referral to treatment times (RTT), ED 4
hour target and cancer waiting times. We
have made significant improvements and
these areas will continue to be a priority for
us in the year to come.
On 24 June 2014, the CQC published the
Quality Report of the Trust-wide inspection it
undertook in March 2014. The overall rating
for the Trust was “requires improvement”. A
robust action plan has been implemented to
focus on the risks identified. We have made
significant strides in addressing the areas
requiring improvement and will continue to
do so in 2015/16.
The Quality Account is by no means the only
work we will be completing to improve our
services. We are refreshing year 2 of our
Quality Strategy to be implemented by
2018/19. This document is the foundation to
support delivery of the highest quality
healthcare services to our patients and sets
our direction for making measurable
enhancement to the quality of our services:
Patient Safety: In 2015/16 we will continue
to focus on improving our maternity
services. Staffing and facilities have been
improved and the unit obtained baby friendly
status.
We redesigned pathways to utilise
the
new
ED
(Emergency
Department) Observation Ward
which opened in October 2014.
Prompt
initial
senior
clinical
assessment within ED and rapid
referral if admission is required
continues to aid flow within the
department
along
with
an
ambulatory approach to medically
expected patients within the Acute
Medical Unit. These improvements
are helping to support us to cope
with the demand and pressure and
deliver the 95% quality standard.
In April we launched our Sign up to Safety
Campaign designed to reduce avoidable
harm to patients. We will also improve our
ability to learn from incidents, further
developing the right culture, systems and
processes to enable us to learn from
incidents and employ a zero tolerance to
never events. To address these we know we
need to further develop our learning
structures.
Clinical Effectiveness:
Our immediate
attention is on continuing to improve the
quality and management of our patient
medical records and waiting times for
patients. These impact on patients and the
efficient running of the hospital. We
recognise that the current systems need to
be improved. We therefore will be seeking to
improve the quality of all the information that
we use in relation to patients, supported by
development of our clinical audit and
governance process.
We will undertake further work to reduce
waiting times to ensure treatments are
received at the right time. There will be
particular focus on referral to treatment times
and cancer waiting times.
Patient Experience: We will be working to
improve safe and timely discharge of our
2
patients as well as developing administration
systems to improve booking processes,
reduce cancellations and improve access to
the Trust.
Culture: We recognise the most valuable
tool we have for improving the quality of care
is our workforce. We will continue to
develop our organisation to ensure that we
align all services on our culture of caring,
learning and leadership. We accept that our
focus on quality must be ongoing and
relentless in order to deliver the services our
patients and community deserve.
I am very pleased to present this Quality
Account to you and I believe that it is a fair
and a balanced report on the quality of care
at the Royal Berkshire NHS Foundation
Trust. I also confirm that, to the best of my
knowledge, the information contained within
this report is accurate
.
*Insert signature (colour)*Jean
O’Callaghan, Chief Executive xxx May
2015
3
Introduction
What is a Quality Account?
Since 2009, all NHS hospitals must
publish a Quality Account. The Quality
Account is an annual report to the
public by NHS providers of the quality
of the services provided. Its purpose is
to ensure NHS trusts demonstrate
their commitment to delivering high
quality care, openness and candour
and to invite the stakeholders to
contribute to determining the
standards of care they desire and
expect.
This document is Royal Berkshire
NHS Foundation Trust’s (‘the Trust’)
Quality Account for 2015/16 and it is
divided into three sections.
Part 1: A statement from the Chief Executive on quality. We have also set out an
introduction to the Trust and what quality means to us.
Part 2: An outline of our quality improvement priorities for 2015/16. This includes
how we have chosen those priorities through consultation. In this section we have
included mandated statements of assurance from the Board on clinical audit,
research, CQUIN payments and data quality.
Part 3: We review 2014/15 and comment on our performance against our priorities
for the year. We have also included highlights of other areas of quality
improvement that have been important to us and to our patients. This includes
information on national and mandated core indicators for 2014/15, including
benchmarking.
Annex: We have included statements from our local key stakeholders such as
Healthwatch, Health and Wellbeing Boards and the Commissioners of the services
we provide.
4
About Royal Berkshire NHS Foundation Trust
Royal Berkshire NHS Foundation Trust provides high quality acute medical and
surgical services for our local communities for over 500,000 people in Reading,
Wokingham, West Berkshire and surrounding areas. We also provide specialist
services to a population of one million across Berkshire and its borders. With just
over 4,500 staff we are one of the largest employers in the Reading area.
Our specialist centre is the Royal Berkshire Hospital in Reading, a large district
general hospital with the expertise to treat patients requiring urgent or hyper-acute
care.
We provide services from the following bases:
Royal Berkshire Hospital, Reading with just under 700 beds and capacity for
over 200 day patients.
Additionally we have a number of community sites where we deliver ambulatory care
and diagnostics. We continue to develop the range of services offered in the
community to take a greater proportion and range of care nearer to, or at, patient’s
homes (Figure 1).
Figure 1: RBFT hospital sites
5
The Prince Charles Eye Unit, Windsor, provides eye services to the patients
of East Berkshire
Dialysis services at a dedicated unit in Windsor
West Berkshire Community Hospital - day surgery unit and the acute
outpatients department.
Royal Berkshire Bracknell Healthspace – cancer, renal and outpatient
services.
Townland’s Hospital, Henley – outpatient services.
We have been an NHS foundation trust since June 2006 and we are pleased, with
the freedom and responsibilities that this brings. It enables us to work with our
members through our Council of Governors to shape our direction of travel. Working
with Commissioners we can develop the services and facilities required by our local
communities.
We are a designated specialist centre in cancer, bariatric care, heart attack and
stroke. We also provide specialist care as part of a care network through a local
neonatal unit, an interventional radiology unit and a trauma unit. We are part of the
critical care and vascular care networks.
6
Our approach to quality
Our mission is to
always provide our
patients with services
that are safe,
clinically effective and
person centred:
Patient Safety
This is about treating and
caring for people in a safe
environment and how we
ensure we protect them
from any avoidable harm.
Clinical effectiveness
This is about whether or not
a patient’s care or
treatment is successful. In
other words – did it have
the impact it was supposed
to have and did it achieve
the best possible result for
the patient?
Patient experience
Having patient-centred care
is about ensuring that
patients, relatives and
carers have as positive
experience as possible at
every stage of the care or
treatment provided. This is
about their overall
experience throughout the
entire course of their
treatment – not just the
result at the end.
Our commitment to quality is
summarised in our vision to
“provide sustainable, and
improving, high quality care for
our local community”.
In support of this revised vision we are
refreshing our Quality Strategy, containing
our quality objectives and plans around
strategic themes. These themes are:
High quality care: A commitment to deliver high
quality care that is safe, compassionate and
effective, which provides a positive experience.
This will be underpinned by effective clinical
governance and risk management processes.
Financial sustainability: Achieving financial
stability, resilience and sustainability in the longer
term that allows investment in front line services
that are fit for the future.
Transforming services: Ensuring our services
meet the needs of the local population by
responding to the changing needs of our patients,
Commissioners and the local health and social
care environment in order to bring maximum
benefit through integration.
Organisational resilience and capability:
Improving how we align all the components of our
organisation that define us – our estate,
workforce (capacity and skills), technology, our
culture of caring & learning and our leadership
capability.
We know that one of the biggest risks to
delivery of quality health care is affordability.
We have set ambitious standards of care
that we will seek to achieve by 2018/2019.
However, we acknowledge that we have to
deliver significant savings over this period.
We have in place a robust Quality Impact
Assessment process which is used to
measure and to monitor the potential impact
that cost savings may have on the quality of
care.
7
How do we know we are delivering quality care?
The Trust Board is accountable for the
systems of assurance, internal control
and risk management and regularly
monitors and reviews these at Trust
Board level and via its committees.
The Chief Executive is ultimately
responsible for ensuring the Trust
delivers a high quality service for all
patients and for the delivery of and
compliance with assurance, quality
and performance targets. This
responsibility is delegated to members
of the Executive, such as the Medical
Director, the Executive Director of
Nursing, and to the Director of Finance
for financial targets.
experience, speaking with both staff
and patients.
The Executive Team and the Care
Groups meet every month to discuss
and monitor progress against our
quality indicators. A scorecard is used
to help the Trust monitor performance.
This is supported by a dashboard
which focuses attention on those
areas that require further work. The
quality scorecard and the actions are
reviewed bi-monthly by the Clinical
Governance Committee and are
reported and discussed at the Trust
Board every month.
Patient experience/patient
feedback
The Board is actively engaged in
reviewing the quality of our services.
The Chief Executive, Chairman and
the Executive Director of Nursing take
part in regular ward visits to meet staff
and talk with patients. Throughout the
year, we hold monthly Patient Safety
and Patient Experience departmental
visits. Teams consisting of executive
directors, senior nurses, estates and
facilities, corporate and operational
managers visit all our sites to assess
safety, the environment, patient
The Trust Board gains assurance on
quality through a number of reports
including:
The monthly Quality Performance
Report (key performance indicator
dashboard)
Periodic quality and safety reports
Regulatory assurance including
compliance with external
regulators and Commissioners
Board visits to wards and
departments
Patient complaints
Safeguarding
The learning from incidents
The Trust also monitor progress
against CQUIN targets:
Commissioning for Quality and
Innovation (CQUIN) is a scheme
designed to encourage NHS Trusts to
improve quality and patient safety by
setting targets and rewarding
achievements of those targets through
financial payments. These targets are
set nationally, regionally and locally.
8
Quality improvement journey
We know our ability to learn from the
past is critical to our ability to improve
in the future. Therefore we have
reflected on how we have achieved
success in sustaining and growing
improvement since 2011 (figure 2).
This helps us to reflect on those areas
that are a greater challenge and that
may warrant an increased profile and
attention over a period longer than 12
months.
Figure 2: 2011/12-2015/16 Quality Improvement Priorities
Patient
Experience
Clinical
Effectiveness
Patient Safety
2011/12
2012/13
Reducing numbers of patients who develop
C. difficile
Reducing harm
from VTE, falls
and sepsis
Reducing harm
from sepsis
Improving care
for patients with
dementia
Ensuring timely
and informed
discharge
2013/14
Reducing the
number of
pressure ulcers
Improve the
appointments
system
2014/15
Reducing and
preventing
C.difficile
infections
2015/16
Improving learning
from Patient safety
Incidents
Improving Harm
Free Care: falls,
UTI, pressure
ulcers, VTE
Improving the
safety of our
maternity
services
Understanding
and reducing
weekend
mortality
Reducing waiting
times to ensure
treatments
recieved at right
time
Improving availability and quality of medical
records
Improving
discharge
communications
to patients
Improving our courtesy, communication and behaviours
Improving the
outpatient
experience
Reducing
cancellations
Improving safe
and timely
discharge for
patients
Improving
administration
systems to
improve booking
processes,reduce
cancellations
9
Part 2:
Priorities for Improvement in 2015/16 and Board
Statements of Assurance
2.1 Priorities for
improvement in 2015/16
Our high level Trust objectives are to
ensure that patients are safe from
harm, they receive clinically effective
treatment and they have a positive
experience whilst in our care. This
year we have chosen six priorities for
improvement that fall within these
three high level groups.
How did we choose
priorities for 2015/16?
priorities will be meaningful and
relevant to our key stakeholders, whilst
ensuring that we continue to give
appropriate purpose and focus to other
priorities over a longer period.
Patient Safety
Reducing avoidable harm; providing safe care; and
embedding sustainable mechanisms for patient
safety improvement. Our chosen priorities are to:
1.
our
At any NHS organisation there are a
large number of quality improvement
initiatives being delivered at any one
time, with a range of improvements
happening across corporate
departments and clinical care groups.
It is necessary to focus our attention
on a number of priority objectives that
directly reflect what our partners,
patients and staff are saying to us.
Last year we developed our Quality
Strategy which highlights our
improvement priorities over the five
years to 2018/9. We are currently
refreshing the second year of this
strategy.
The Quality Account priorities form a
key element of the Quality Strategy. It
is our aim to align our priorities with
those of our Commissioners and our
patients and staff, to ensure that we
have the supporting strategies that will
underpin successful delivery. As a
result, we are confident that these
2.
Improving the reporting of patient safety
incidents and the systems for learning from
them
Improving the safety of our Maternity Service
Clinical Effectiveness
Treating patients effectively to improve their health
and quality of life; continually monitoring clinical
outcomes against agreed measures; and comparing
our performance with other similar Trusts. Our
chosen priorities are to:
3.
4.
Improving availability and quality of medical
records
Reducing waiting times to ensure treatments
are received at the right time
Patient Experience
Understanding what matters to our patients and
improving their experience of care in hospital. Our
chosen priorities are to:
5.
6.
Improving safe and timely discharge of patients
Improving administration systems to enhance
booking processes, reducing cancellations and
increasing access to hospital
10
Our approach this year has centred on
three significant exercises:
Listening to our staff: for the
second year running as part of
our commitment to engage with
our staff and capture feedback
and suggestions for
improvement, we held a large
series of listening events
across the Trust. In addition to
the findings being reviewed by
the Board, Executive and Care
Groups the themes have been
reflected in the list of quality
priorities on which stakeholders
were asked to prioritise for
inclusion into the 2015/16
Quality Accounts.
Strategic approach: We used
the ideas and challenges
presented by these discussions
to refresh our longer-term
Quality Strategy as our core
driver for improvement.
This sets out the steps we will
take to make real and
measurable improvements to
the quality of services,
underpinned by a robust
programme of quality impact
assessments. We have
appointed a new Director of
Organisational Development
who plans to develop our
Organisation Development
strategy by June 2015.
Stakeholder engagement: A
long-list of quality objectives
was identified as part of our
five year strategy and we
shared these with our
stakeholders in February 2015.
The various parties involved
included our Commissioners,
Healthwatch, Health and
Wellbeing Boards, Governors,
patients and our staff. Their
feedback was used to identify
the priorities we have included
in our 2015/16 Quality Account
(figure 3).
Figure 3: Quality Engagement process
11
Priority 1: Patient safety: To improve the safety of
our Maternity Service
Our Maternity Service
Why have we chosen this priority?
Our maternity service is a core
service within the Trust providing
comprehensive obstetric and
midwifery care for 5500-6000
deliveries per annum. Over 90%
of women living in Reading and
Wokingham and around 50% of
women living in Newbury choose
to deliver their baby within the
Royal Berkshire Foundation Trust
(RBFT) service.
During 2014, our maternity service found itself
at a crossroads where several external
pressures (reaching capacity in birth numbers, a
challenging recruiting environment, and an
ageing building) resulted in a decline in the
quality of service it aspired to. This was
reflected in the 2014 CQC inspection which
reported maternity services overall to be “in
need of improvement”.
We provide community and
hospital care through pregnancy
and delivery. Our service is
designed to offer as much choice
to women as possible both about
their care and where they receive
it. Our service ensures safety and
quality of care is maintained
within the decision making
process.
We participate in national
initiatives for developing maternity
care. In December 2014, we
celebrated achieving ‘Baby
Friendly' status – part of a global
accreditation programme from
UNICEF and the World Health
Organisation designed to support
breastfeeding and to strengthen
mother-baby and family
relationships.
The first step was to commission an external
review of the service by the Royal College of
Obstetricians and Gynaecologists. As a result
an improvement programme was implemented
in October 2014. The purpose of the
improvement programme is to enable and
support significant change in the way in which
the maternity service carries out its functions, by
meeting both the recommendations of the
external review and the compliance criteria of
the CQC. Of paramount importance is the
service provides woman centred care to
national standards in order to enhance the
experience of women.
The action plan is designed to deliver change in
three phases; immediate (0-6 months), medium
term (0-9 months, and long term (0–12
months+). It is based around the five evaluation
criteria of the CQC and managed through three
workstreams; safe and effective; caring and
responsive; well lead.
The safe and effective work focuses on
delivering change required to improve the
current service model and includes
management structures, governance;
operational staffing; and improving the real
estate to create a safer environment.
12
The caring and responsive work
focuses on listening to staff and
feedback from women on our
performance and the culture that
underpins it. Inter professional teams
will work together to identify and
deliver improvement activities from the
feedback in order to
increase engagement, morale and
improve women’s’ satisfaction.
The well led workstreams focuses on
leadership and strategy to enable the
future development of the service to
meet the requirements of women and
stakeholders.
What did we do in 2014/15?
Reviewed our management
structures to ensure there is
greater accountability for service
quality.
Reviewed and improved the
governance processes to provide
robust assurance.
Increased the consultant
establishment by two to support
the current birth rate.
Commissioned a ventilation
project on delivery suite to
improve air exchange and
temperature control.
How will we improve in 2015/16
Reviewed feedback from both
staff and women surveys to
identify areas for improvement.
Commenced a Strategic
Leadership Programme –
supported by Thames Valley
Leadership Academy
Completed benchmarking visits to
other Trusts to identify new
operating models and leading
edge practices.
How will we monitor and report
progress?
In the next year we aim to:
1. Reinvigorate our vision, strategy for
future development and planning so
we can confidently meet our service
needs.
2. Strengthen our service culture so it
is characterised by strong
professional relationships and team
working with the ability to
continuously improve embedded
into the service.
3. Undertake a number of
improvement projects including the
implementation of the K2 maternal
and foetal monitoring system.
Progress will be monitored through our
Improvement Programme Board and
overseen by the Trust Improvement
Steering Group and also through our
Quality Schedule which is monitored
with our Commissioners. The
programme has a number of key
performance indicators which are
measured monthly and demonstrate the
impact the improvement work is having
on the service. The key indicators we
will monitor are the percentage of
unexpected admission >37 weeks to
NICU (neonatal intensive care unit and
the midwife to birth ratio to support
safer child birth.
4. Review the Kirkup report
recommendations following events
at Morecambe Bay
13
Priority 2: Patient Safety: Improve learning from
patient safety incidents and our systems for learning
from them
Why have we chosen this priority?
Incident reporting
We aim at all times to provide a harm free environment but
occasionally, despite our best efforts, patients encounter
harm, for example if they slip or fall. We know that in order
to be safe, we must promote an open culture for staff to
report and learn from these events. The NLRS (national
learning reporting system) highlighted the Trust as an
outlier when benchmarked with other Trusts in the number
of incidents reported per 100 admissions.
Incident reporting gives us an
opportunity to learn from past
events and to ensure that steps
are taken to minimise
recurrences.
Research has shown the more
incidents that are reported the
more information is available
about any issues and the more
action can be taken to make
healthcare safer for our
patients, staff and visitors.
We consider it very important that we learn when things go
wrong, one way of learning is through reporting and
managing incidents and we take this process very
seriously.
In 2014/15 we reported 10129 patient safety incidents.
What did we do in 2014/15?
We have worked hard to increase our incident reporting over the year and have
made steady progress and are no longer considered an outlier.
How will we improve in 2015/16?
1. We aim to improve the
We intend to implement the following:
reporting of incidents
2. We aim to improve our
sharing of incidents
outcomes and learning
to relevant parties
3. We will continue to drive
a culture which
encourages asking staff
to speak up and speak
out and ‘zero tolerance’
to never events
In April 2015 we will be launching our “Sign up to Safety”
campaign. The campaign will be an opportunity to raise
awareness of safety issues including the importance of an
incident reporting culture and the importance of learning. As part
of the campaign we will intend to recruit and develop 10
volunteers to become ‘Safety Ambassadors and 20 staff to
become ‘Safety Makers’.
How will we monitor and report progress?
We have robust processes for the management of incidents and
near misses where every incident is graded and analysed, and
where required undergoes a root cause analysis report.
Trends and themes are identified from the incidents and these
are circulated across the organisation for action by care groups,
directorates and departments and monitored through the clinical
governance structure. The Patient Safety Committee will oversee
implementation of this priority.
14
Priority 3: Clinical effectiveness: Improving the
availability and quality of medical records
What is a medical
record?
Every patient has an
individual medical record
(sometimes called a health
record) that contains personal
information, age and address,
treatments planned and
received, any allergic
reactions, prescribed
medicines, and results of
investigations carried out
such as blood tests and xrays
What did we do in 2014/15?
Actions completed to date are as follows:Changes to the way in which records are delivered
to Outpatient Clinics to improve availability.
Identification of 32 ‘Champions’ from various staff
groups across the Trust to help communicate and
support the need for improvement with their peers.
Development of KPIs (key performance indicators) to
enable monitoring of progress going forwards.
Feasibility study completed for implementation of
electronic tagging to improve storage and availability
of records. We undertook two main reviews that
identified the extent of the problem with regard to
records management
•
•
Why have we chosen this
priority? (Continues to be a
priority)
The medical record is vitally
important in supporting the clinical
pathway and in the provision of
safe patient care. We are
increasingly aware the quality and
availability of medical records
needs to improve and a more
robust approach to the
management of health records is
required. We have completed a
consultation with external and
internal stake holders (including
staff, patients, Commissioners,
Governors, Healthwatch and this
was determined to be a priority).
Security of Records Audit
Quality of Content Audit
How will we improve in 2015/16?
1. An Improvement Plan for medical records has been
agreed with key performance indicators (see figure
X) which we will monitor
2. Work stream Leads identified and regular meetings
are held with working groups.
3. Progress & concerns are discussed at the monthly
Steering Group Meetings and escalated to the
Trusts Improvement Programme Steering Group.
4. Increase availability notes available to the clinical
staff by the time of the clinic appointment from
97.8% to 99%
5. Increase the number of inpatient cases coded from
notes to 80%
6. Improve the content of medical records through
regular audit and improvement activity
15
How will we improve in
2015/16?
Medical Records management and
processing will be reviewed and
enhanced to provide a standardised
way of working. Actions include:
Standardised / improved storage
facilities for wards and clinics
Complete monthly audits of the
quality of content and the
completeness of our medical
records, and KPI reporting
Review current content of patient
records with a view to standardise
and streamline (reduce) the
volume of paper
Provide alternative “fit for purpose”
accommodation for the Health
Records Department – Off-site
premises identified to bring inhouse all medical records thus
enhancing availability of records
Load letters onto our Electronic
Patient Record (EPR) – Discharge
Summaries, Results, GP Referrals,
Outpatient Letters, and
Operation/Theatre Notes. One
view of co-modalities / allergies
Review of tracking locations across
the Trust
Agree our Information Technology
(IT) Strategy leading to “paper
light” processing
Implement automatic requesting of
notes for all wards to support
weekend admissions
Training & education programme
to be developed to include:
o Level 1 – Basic Information
Governance Awareness
o Level 2 – Intermediate
Consultant/Clinician level
(Understanding the
process, Quality of
Content)
o Level 3 – High level users
(day to day records
management, EPR(
Electronic Patient Records)
Enhance patient record availability
by implementing latest volume and
last volume unless full set of notes
required by clinician
How will we monitor and
report progress?
KPIs are in place and will be
monitored Trust-wide, at Care Group
and local Clinical Governance
meetings to ensure compliance and
standards are maintained.
16
Priority 4: Reducing waiting times to ensure
treatments received at the right time
National Standards
The Referral to Treatment
(RTT) operational
standards is that 90 per
cent of admitted and 95
percent of non-admitted
patients should start
consultant-led treatment
within 18 weeks of referral.
In order to sustain delivery
of these standards, 92 per
cent of patients who have
not yet started treatment
should have been waiting
no more than 18 weeks.
Why have we chosen this priority?
Cancer Targets: Despite a marked
improvement in Quarter 3 performance
across all 5 reported Cancer standards
the Trust failed to achieve the
cancer 62 day (GP referral) target but
remains on an improving trajectory.
The Trust delivered sustained
improvement across both 2 Week wait
targets achieving national standards in
quarter 4.
The Cancer 2 week wait (2ww)
Target failed October due to a high
number of capacity related breaches,
primarily in endoscopy. These
improved markedly in November and
December. An additional endoscopy
room is underway and the gastro team
are looking at the provision for 6 day
working. December performance
dipped largely as a result of patient
choice over the Christmas period.
17
18 week RTT. Data reporting of 18
week RTT data were suspended for
six months in 2014/15 due to ongoing
validation processes in relation to its
recording and reporting of RTT
performance. A very challenging “data
cleansing” plan was agreed with
Monitor and commenced in November
2014. All milestones within this plan
have been achieved, the main impact
being the reduction in the size of the
Trust Patient Tracking List from
>80,000 patients to 26,000. Reporting
resumed in January 2015.
What did we do in 2014/15?
We have been working with Planned
Care and Informatics specialists to
develop, implement and embed
processes and disciplines, providing
greater assurance to our Trust Board.
Figure 4: RBFT waiting times targets/indicators 2015/16 Q4
Targets or Indicators Not Met
90%
95%
92%
95%
2014/15
Quarter 4
(Actual)
70.3%
94.6%
90.3%
92.43%
85%
80.4%
Target
RTT 18 weeks - Admitted
RTT 18 weeks - Non-admitted
RTT 18 weeks – incomplete pathways
A&E Wait < 4Hours
Cancer 62 Day Waits for first treatment (from urgent GP
referral)
How will we improve in 2015/16?
1. We aim to make our
system efficient whilst
improving the quality of
care provided to our
patients by designing a
programme of work with
the aim to promote
boundary-less patient
flow where we think about
the patient journey
beyond just the 4 walls of
a hospital.
2. We aim to achieve the
national targets for RTT,
A&E access and Cancer
waiting times
We will be implementing our new patient
flow programme of work which has six
workstreams: Ambulatory Care –
Medicine; Ambulatory Care - Emergency
Surgery; Effective Wards; Integrated
Discharge; Elective Day Care Medicine
and Elective Surgical Flow, including
Theatres.
The focus of the Patient Flow programme
will enable a review of each element of
pathways, use best practice and change
processes to improve patient experience.
This would combine aspects of the
existing emergency care, length of stay
and theatre programmes.
How will we monitor and report progress?
Progress will be reviewed by the Patient Flow Steering Group which feeds into the
Trust’s Improvement Programme Board.
18
Priority 5: Patient experience: Improving safety and
timely discharge of patients
Patient flow
Why have we chosen this priority?
Improving ‘patient flow’ is
one way of improving
services to our patients.
Evidence suggests that
improving patient flow also
increases patient safety and
is essential to ensuring that
patients receive the right
care, in the right place, at
the right time, all of the
time. It is essential that
patient flow does not come
at the expense of safety or
reliability.
Right from admission it is important we are working to
smooth and shorten the patient’s pathway ensuring a safe
and seamless transition from the hospital.
In order to be able to meet our 4 hour access target we need
to ensure that there are beds available in the hospital and
the beds available enable our patients to be on the right
ward. Patients on the right ward often have a better
experience and a shorter length of stay. It is our intention to
get the right patient to the right place at the right time. The
longer we keep people in hospital the more risk they have of
infections and other safety concerns, such as pressure
ulcers. If appropriate we aim to discharge patients back to
their own environment as quickly and safely as possible as
rehabilitation in the patient’s home is more meaningful.
What did we do in 2014/15?
We are striving to make our system efficient whilst improve the quality of care provided to
our patients by designing a programme of work with the aim to promote boundary-less
patient flow where we think about the patient journey beyond just the 4 walls of a hospital.
We are developing a Patient Flow Steering Group with 6 workstreams: Ambulatory Care –
Medicine; Ambulatory Care - Emergency Surgery; Effective Wards; Integrated Discharge;
Elective Day Care Medicine and Elective Surgical Flow, including Theatres.
The focus of the Patient Flow programme will enable a review of each element of
pathways, use best practice and change processes to improve patient experience. This
would combine aspects of the existing emergency care, length of stay and theatre
programmes.
How will we improve in 2015/16?
We will consider and address the
findings of the national ‘Inpatient
Survey’ undertaken by Picker. We
review the comments made as part of
the ‘Friends and Family’ survey and
address themes identified.
We will be implementing our Patient
Flow Steering Group, programme and
workstreams:
Continue our work striving for
24/7 working and increasing
the number of discharges at
weekends.
19
Two workstreams of the
Patient Flow work programme
are key to ensuring the safety
and timely discharge of
patients:
We will work to improve the
timely prescribing and
dispending of medication.
Effective Wards Workstream
Aim: to ensure the efficient flow of
patients through the wards, ensuring
each ward is ready to care for the next
patient, and improving the patients'
experience whilst on the ward as well
as decreasing length of stay.
This work will:
- reduce the variation in discharge
across the week
- increase throughput per bed on
each ward
- enable a higher proportion of
medication (TTOs) to be available
prior to the day of discharge
- deliver an effective process in place
to unblock key bottlenecks e.g.
timely therapy input
We will continue to implement
enhanced recovery in our elderly care
wards.
Integrated Discharge Workstream
Aim: to reduce unnecessary delays in the transfer of
patients out of the hospital once medically fit, to
promote discharge to Hospital at Home pathways/
community services once medically stable and to
safely decrease length of stay.
This work will:
- develop and implement hospital at home
pathways for example implementing virtual ward
rounds and other processes to enable patients to
safely receive intravenous (IV) antibiotics, IV fluid or
oxygen at home
- explore how to improve connectivity and enhance
electronic communication between the hospital, GPs
and out of hours services; - enable patients to be
‘discharged to assess’ where patients need for care
packages is assessed in their own home meaning
patients spend less time in hospital, care needs are
more accurate and patients are getting the right care
package from the start.
- further integrate our Respiratory Team and reduce
respiratory admissions
- reduce internal delays to patients reaching
medically fit list e.g. delays in Section 2s. A Section
2 requires an NHS body to notify social services of a
patient’s likely need for community care services
after discharge.
How will we improve in 2015/16?
1. We will aim to increase the percentage of patients
being discharged before noon
2. We will aim to reduce the number of patients being
discharged after 9pm
How we will monitor and
report progress?
Progress will be reviewed by the
Patient Flow Steering Group
which feeds into the Trust’s
Improvement Programme Board.
3. Reduce delayed transfers of care
20
Priority 6: Patient experience: Improving
administration systems to improve booking
processes, reducing cancellations and improve
access to hospital
Why have we chosen this priority?
Concerns about clinical treatment,
communication, administration,
personal care and building,
environment and equipment form the
top themes regarding formal
complaints. While actions are taken to
address informal concerns raised via
Patient Advice and Liaison Service
(PALS) on an individual basis, learning
from both PALS and formal complaints
is shared across the care groups to
address overarching themes.
The number of complaints raised
about administration was 58 during
2014/15, with the majority of
complaints relating to behaviour and
attitude (75).
Improving our administration
processes, better use of technology
and roles will improve the patient
journey and patient experience.
What did we do in 2014/15?
We have begun to review our
administration processes, technology
and administration roles that support a
patient journey in order to align the
clinical administration support to the
clinical pathway of patients and
provide a single point of access for
patients and GP’s.
We have set up a Clinical
Administration Programme Board to
oversee the implementation of this
work programme. There are four
workstreams: Human Resources,
Technology, Operations and
Standards Operating Procedures and
Estates and Facilities. These are to
address the key areas which will be
impacted in the programme.
How will we improve in 2015/16?
1. We intend to implement a new
administration structure to support
clinical administration to the
clinical pathways.
2. We intend to implement a single
point of contact for patients & GPs
3. Reduce our DNA rate
4. Reduce appointment
cancellations,
We intend to reconfigure the function of
the patient services team and implement
a new administration structure to support
clinical pathways. This will involve
development of a detailed structure, job
descriptions, consultation and
appointment of staff as well as detailed
estates planning, technology planning,
improving the IT and telephone
infrastructure that support the teams.
Communication and engagement will be
key through all stages of this work
21
programme.
We intend to implement a single point of contact for patients & GPs to their
spcecialist care.
How we will monitor and report progress
It is our aim to:
- reduce appointment
cancellations,
- increase the number of calls
answered and reduce
abandoned calls
improve clinician experience
and pathway delays by
improving letter turnaround
times
reduce the number of patient
complaints relating to
administration
improve the efficiency and
consistency of clinics through
improved management of
consultant annual leave and
robust cross cover at team
level
We intend to measure the following:
- Did not attend (DNA) rate
The number of patient
complaints relating to clinical
administration
improve data quality and
utilisation of EPR by
standardising to best practice
all workflows and standard
operating procedures
improve the administration
staff job satisfaction by having
clear career development in
place
improve the overall service
experienced by our patients
through customer service
training and standardising
practice
provide greater control to the
clinicians for managing their
business
Progress will be monitored through the
Clinical Administration Steering Group
and reported through the Improvement
Programme Board
Monitoring will be undertaken by the
Care Groups and monthly reports on
progress presented to the Board.
22
2.2 Statements of assurance from the Board
As a provider of NHS services we are
required to include statements of
assurance from the Board on the
quality of our data and governance
arrangements within our Quality
Account.
2.2.1 Review of our services
During 2014/15 the Royal Berkshire
NHS Foundation Trust provided and/or
sub-contracted 33 relevant health
services. The Royal Berkshire NHS
Foundation Trust has reviewed all the
data available to them on the quality of
care in 33 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 the Royal
Berkshire NHS Foundation Trust for
2014/15.
2.2.2 Participation in national clinical audits and national
confidential enquiries
National clinical audit provides
assurance that the care being
delivered by our services is of the
highest quality, in terms of clinical
effectiveness, patient outcomes and
patient experience, compared to both
national best practice standards and
other service providers nation-wide.
to improve the quality of care being
delivered to patients.
Where the care being delivered does
not meet these standards, it provides a
stimulus for improvement in the quality
of treatment and care. National clinical
audits also provide a measure for
organisations to be compared with
other care providers across the
country.
During this period Royal Berkshire
NHS Foundation Trust participated in
90.9% national clinical audits and
100% national confidential enquiries of
the national clinical audits and national
confidential enquiries which it was
eligible to participate in.
National confidential enquiries are
national reviews of high risk medical or
surgical conditions which produce
recommendations to be implemented
During 2014/15 33 national clinical
audits and 3 national confidential
enquiries covered relevant health
services that Royal Berkshire NHS
Foundation Trust provides.
The national clinical audits and
national confidential enquiries that
Royal Berkshire NHS Foundation
Trust was eligible to participate in
during 2014/15 are as follows:
23
Figure 5 National clinical audits and national confidential enquiries participated in by
the Royal Berkshire NHS Foundation Trust 2014/15
Title
Participation Rate/Comment
National Clinical Audits
1. Falls and Fragility Fractures Audit
Programme (FFFAP), National Hip
Fracture Database (NHFD)
2. National Comparative Audit of Blood
Transfusion – Audit of Transfusion in
Adults and Children with Sickle Cell
Disease
3. Renal Replacement Therapy (UK
Renal Registry)
4. Rheumatoid and early inflammatory
arthritis
5. Emergency Laparotomy (NELA)
100%
6. Patient Reported Outcome Measures
Groin Hernia – 43.4%
Hip Replacement – 53.5%
Knee Replacement 65%
Varicose Vein – 43.5%
(PROMS) *
100%
100%
10 cases submitted – denominator
unknown
98%
* Figures based on the most recent data – April 2014
to February 2015.
7. Head and Neck Cancer (DAHNO)
8. Bowel Cancer National Audit
100%
100%
(NBOCAP)
9. Oesophago-Gastric Cancer Audit
(NOGCA)
10. Lung Cancer Audit (NLCA)
Data collection in progress – deadline for
submission May 2014
11. Prostate Cancer
12. National Joint Registry
13. Trauma Audit and Research Network
(TARN)
14. Acute Coronary Syndrome (MINAP)
15. Cardiac Rhythm Management
16. Coronary Angioplasty
17. National Heart Failure Audit
18. Fitting Child (Care in Emergency
Departments) (CEM)
19. Mental Health (Care in Emergency
Departments) (CEM)
20. Older People (Care in Emergency
Departments) (CEM)
21. Adult Critical Care ICNARC
22. National Pregnancy in Diabetes Audit
(NPID)
Data collection ongoing – data entry
deadline 1st June 2015
Data collection ongoing – data on 304
patients submitted (April-February 2015)
100%
100%
100%
100%
100%
85% (estimate)
100%
23 cases submitted. Denominator
unknown.
30 cases submitted. Denominator
unknown.
100%
100%
24
23. Epilepsy 12
24. National Neonatal Audit Programme
100%
100%
(NNAP)
25. National Paediatric Diabetes Audit
26. Adult Community Acquired Pneumonia
(BTS)
27. Pleural Procedures
28. National Chronic Obstructive
Data collection in progress – data entry
deadline 30/06/2015
Data collection in progress – data entry
deadline 31/05/2015
45%
50%
Pulmonary Disease (RCP)
29. National Cardiac Arrest Audit
30. Sentinel Stroke National Audit
Programme (SSNAP)
National Confidential Enquiries
1. NCEPOD GI Haemorrhage
2. NCEPOD Sepsis Study
3. Maternal, infant and perinatal mortality
(confidential enquiry)
100%
100%
100%
100%
100%
Figure 6: National clinical audits and national confidential enquiries not participated in
by the Royal Berkshire NHS Foundation Trust 2014/15
Title
National Clinical Audits:
1. Congenital Heart Disease (Paediatric
cardiac surgery)
2. National Adult Cardiac Surgery Audit
Reason for Non-Participation
RBH not eligible to participate
RBH not eligible to participate
3. National Vascular Registry
RBH not eligible to participate
4. Pulmonary Hypertension Audit
RBH not eligible to participate
5. Chronic Kidney Disease in Primary
Care
6. Prescribing Observatory for Mental
Health (POMH)
7. Paediatric intensive care (PICANet)
RBH not eligible to participate
8. National Diabetes Audit – Adult
Most adult out-patient diabetic care is
provided by the Community; the Royal
Berkshire Diabetes Centre only looks after
children, adolescents, pump patients and
pregnant women. It was therefore felt there
were too few eligible patients to make it
worthwhile for the RBH to participate in the
adult element of the National Diabetes Audit
programme. The Paediatric, Inpatient, and
RBH not eligible to participate
RBH not eligible to participate
25
9. National Audit of Intermediate Care
10. Inflammatory Bowel Disease
National Confidential Enquiries:
1. Mental health clinical outcome review
programme: National Confidential Inquiry
into Suicide and Homicide for people with
Mental Illness (NCISH)
Pregnancy in Diabetes Audits are fully
participated in by the RBH.
The aim of this audit is to review
‘intermediate care’ – a range of integrated
services to promote faster recovery from
illness, prevent unnecessary acute hospital
admission and premature admission to
long-term residential care, support timely
discharge from hospital and maximise
independent living. It therefore covers a
range of service providers, with just a small
part relevant to acute care. Newbury and
District CCG have not signed up to
participate in this audit and so it was not felt
worthwhile for the Trust to participate as the
whole care pathway for these patients could
not be assessed. This is not an “NCAPOP”
audit therefore participation is optional.
This round of the audit was concentrated on
submitting patients Biologics data to a
database. For this year the department did
not have the manpower to support this data
collection. For the forthcoming year this
issue has been resolved.
RBH not eligible to participate
Results of national clinical audits and national confidential
enquiries
The reports of 18 National Clinical
Audits and 3 National Confidential
Enquiries were reviewed by the
provider in 2014/15. Some of the
highlights from our national clinical
audit results published in 2014/15 are
given below:
National Paediatric Diabetes Audit
(published October 2014)
Business case for Paediatric
Diabetes Specialist Nurse
submitted
Podiatry assessments in clinic
for those patients not attending
podiatry appointments
Targeted support for patients
with high average blood sugar
levels in order to prevent
patients developing diabetes
related complications
26
Hip Fracture Database (published
September 2014)
Trust bed reconfiguration to
allow the formation of a hip
fracture unit into which we are
able to directly admit hip
fracture patients.
A re-launch of “A to Z” for
medical management of preoperative fragility fracture
patients. The new elective
orthopaedic unit has daily neck
of femur repair lists which has
improved capacity.
National Audit of Seizure
Management Annual Report
(published January 2014)
73.3% of patients were reviewed by a
Senior Registrar or Consultant (in
comparison to 58% nationally); and
100% of patients were reviewed within
4 hours of arrival at Emergency
Department (nationally 88.8%). At the
Initial ED assessment all key
diagnostic tests (temp/ pulse/ blood
pressure/ Oxygen Saturations/
Respiratory rate / Glasgow Coma
Scale) were completed for 100% of
patients.
British Thoracic Society Paediatric
Asthma Audit (published March
2014)
We have improved in 3 areas out of 5
areas of improvement identified on the
action plan for the previous round of
the audit. We now have minimal use of
chest X-ray (3%) and have
dramatically reduced usage since
2011 (61%). We now have less than
average use of antibiotics (19%) and
have reduced prescribing since 2011
by 50%. We have improved checking
and recording of inhaler technique
before discharge 53% this year
compared with only 14% in 2011.
Hip Fracture Database (published
September 2014)
For the majority of the indicators for
this audit the Trust scored above or
within the National average. 100% of
patients had a falls risk assessment
prior to discharge as well as a Bone
Health Assessment completed.
Inflammatory Bowel Disease Audit
Annual Report (published June
2014)
The Trust has Transitional care
arrangements in place for adolescents
(only 53% of hospitals audited had
arrangements in place). Educational
events are held for patients and
families but less than half the hospitals
audited offered this service. The Trust
has low admission rates overall and a
low non-elective surgery rate. There
was also above average completion of
the nutritional screening tool for
patients.
Results of local clinical audits
Local-level clinical audit projects tend
to be more specialised and smaller in
scope than the national audit projects,
but have the advantage of more rapid
cycles of data collection and quality
The reports of 21 local clinical audits
were reviewed by the provider in
2014/15. Some examples of quality
Improvements that have been
improvement work; this means
patients can experience the benefits of
the changes implemented more
quickly.
implemented as a result of local
clinical audit activity in the Trust
2014/15 are given below:
27
Empirical Antibiotic Treatment
Audit
Session on how to prescribe
and review empirical antibiotic
treatment as part of the
compulsory teaching for
foundation year (FY) doctors
(FY1 and FY2).
smartphone application with
the Adult Medicine Antibiotic
Protocol
Inpatient Hypoglycaemia at RBH:
Potential Causes, January 2015
Development of Hospital
Hypoglycemia guidelines (to
include section to identify &
manage ‘’at risk’’ patients)
Admission sheet to include
section to identify patients at
risk.
Use of at risk bands for
patients
Trustwide Audit of Healthcare
Records
Establish responsibilities from
Record Keeping policy &
disseminated this information
to staff
Documented, processed,
developed and disseminated
via medical records champions
and to all admin staff via ward
and admin managers
Record keeping in Medical /
Nursing induction.
Patient safety hot topic
developed
Healthcare Record Keeping
Policy to be updated and policy
launched with article in
intranet emphasising
standards, reasons for them
and changes to policy
Comment to be included on
audit feedback for specialty
clinical governance meetings
Feedback to care pathways
workstream on need for space
to adequately document
comments
Provide staff with information
on where to purchase stamps if
they wish to use them
2.3.3 Participation in clinical research
There were in excess of 5428 patients
receiving NHS services provided or
sub-contracted by the Royal Berkshire
NHS Foundation Trust as of 20 April
2015 that were recruited to participate
in research approved by a research
ethics committee.
The Trust upholds its commitment to
ensuring that National Institute for
Health Research (NIHR) portfolio
adopted studies are accessible for
patients, relatives and staff to
participate.
An established infrastructure whereby
clinical research runs effectively
alongside usual clinical services and a
workforce model that supports flexible
working both within and across the
Care Groups and Corporate areas
whilst maintaining the high quality and
standards of research conduct
expected within the NHS.
28
We are involved in conducting single
and multi-centre research studies
across the majority of clinical
specialities.
On the 5.3.2015, there are 186
currently active studies and an
additional 56 studies in the participant
follow up phase. 138 (74.2%) of the
active studies and 51 (91%) of the
studies in follow up are NIHR adopted.
13 of the studies have been initiated
by investigators at the Royal Berkshire
NHS Foundation Trust. Over time,
there has been a slow increase in the
number and complexity of investigator
initiated studies. This year the Trust is
acting as the sole Research Sponsor
for its very first multicentre, NIHR
adopted, investigator initiated study
called the POEM study. POEM
(Prescription Of analgesia in
Emergency Medicine), is a
retrospective multicentre observational
study that aims to assess the
adequacy of pain management
(according to the College of
Emergency Medicine - CEM) in
consecutive patients with confirmed
long bone fracture or dislocations
isolated to a single limb, presenting to
Emergency Departments (EDs).
In late 2014 the first collaborative
National Institute of Health Research
(NIHR) study that the Trust coSponsored together with the University
of Reading was published. The study
team developed a new test that could
help more babies born underweight
reach full mental development.
ERIC (the Early Report by Infant
Caregivers) is an easy to use
assessment for parents to detect
delayed learning in babies born
prematurely or with low birth weight.
And over a three year period, 300 preterm or underweight babies were
recruited and assessed as part of the
study funded by the NIHR, Research
for Patient Benefit programme. ERIC
proved to be as effective at identifying
cognitive problems as the Bayley
Scales of Infant Development, the
standard assessment currently used in
clinics. ERIC has potential value as a
quickly administered diagnostic
instrument for the absence of early
cognitive delay in 10- to 24-month-old
preterm infants and as a screen for
cognitive delay which has potentially
huge impact on clinical practice.
Development and validation of a
parent-report measure for detection
of cognitive delay in infancy;
Developmental Medicine & Child
Neurology. Volume 56, Issue 12,
pages 1194–1201, December 2014
We have embraced the challenge of
the government’s commitment to
working with the life sciences industry
to deliver first class clinical research in
the NHS. We exceeded our target for
increasing the number of commercially
funded studies by opening 8 more of
these studies during this year.
We have introduced research activity
into departments with little or no
previous track record of trials radiology, anaesthetics (first pain
study and first drug trial in the
department for 22 years) and with the
appointment of a research midwife
who is an integral part of the paediatric
research team. We now have the
capability to offer opportunities to
participate in research across the
whole of Women and Children’s
services.
Our research activity and infrastructure
demonstrates our commitment to
transparency and desire to improve
patient outcomes and experience
across the NHS. A number of our
studies require additional monitoring
and assessments and this contributes
29
to keeping people well and out of
hospital.
Clinical research highlights our
commitment to improving the quality,
relevance, and focus of research,
whilst adding value and offering the
latest medical treatments and
techniques to our local patient
population.
2.3.4 CQUIN payment framework
A proportion of Royal Berkshire NHS
Foundation Trust income in 2014-15
was conditional on achieving quality
improvement and innovation goals
agreed between the Trust and its main
Commissioners, NHS England and
Berkshire West Clinical
Commissioning Group (acting on
behalf of all commissioning bodies in
Berkshire East, Oxfordshire,
Buckinghamshire, Hampshire and
Surrey), through a quality incentive
framework known as Commissioning
for Quality Improvement and
Innovation (CQUIN). Further details of
the agreed goals for 2014-15 and the
following 12 month period are
available electronically at
http://www.royalberkshire.nhs.uk/about
_us.aspx
The figure below shows quarterly information about our compliance with the CQUIN
framework. For each section in the table, the colour indicates whether we met the
target (green) or did not achieve it (red).
Figure 7: RBFT CQUIN Performance 2014-15
Split of Total
CQUIN value %
Split of Total
CQUIN value
-%
FFT - Staff - Implementation
3.00%
3.00%
FFT - Outpatient Services & Day Surgery - Early Implementation
FFT- A&E & Inpatient Services - Increased or maintained Reponse
Rate
FFT - Inpatient services - Increased Response Rate
3.00%
3.00%
3.00%
3.00%
3.00%
3.00%
Dementia - Find, Assess, Investigate & Refer
3.00%
3.00%
Dementia - Clinical Leadership
2.00%
2.00%
Dementia - Supporting Carers of People with Dementia
3.00%
3.00%
7 Day Working: Assessment by a consultant within 14 hours
30.00%
22.5%*
Reduction in NEL Admissions (Hospital at Home)
15.00%
15.00%
Reduction in NEL Admissions (Hospital at Home)
15.00%
15.00%
End of Life
10.00%
10.00%
G3/G4 Pressure Ulcers
10.00%
10.00%
% of total CQUIN Value
100.00%
92.5%
Newbury District CCG Contract and Co-signatories
*CQUIN is still not finalised and is subject to audit with the Commissioners to determine final outturn. The percentage
disclosed is the expected outturn.
30
Split of Total
CQUIN value %
Achievement
FFT - Staff - Implementation
2.86%
2.86%
FFT - Outpatient Services & Day Surgery - Early Implementation
FFT- A&E & Inpatient Services - Increased or maintained Response
Rate
FFT - Inpatient services - Increased Response Rate
2.86%
2.86%
2.86%
2.86%
2.86%
2.86%
Dementia - Find, Assess, Investigate & Refer
2.86%
2.86%
Dementia - Clinical Leadership
2.86%
2.86%
Dementia - Supporting Carers of People with Dementia
2.86%
2.86%
G3/G4 Pressure Ulcers
13.33%
13.33%
Shared Haemodialysis Care
13.33%
13.33%
Specialised Service Quality Dashboard
13.33%
6.67%
Neonatal Intensive Care – Retinopathy of Prematurity Screening
13.33%
13.33%
Improved Access to Breast Milk in Preterm Infants
13.33%
0.00%
IVIG
13.33%
13.33%
% of total CQUIN Value
100.00%
80.01%
NHS England Specialised Commissioning Contract
Total CQUINs per Accounts £6.24m
In 2013/14 the Trust achieved 95% of
its CQUIN targets and the resultant
income from this source was
£6,554,000. In 2014/15 the Trust it is
estimated that the Trust will achieve
91% of its CQUIN targets and the
resultant income from this source is
estimated to be £6,240,000. The Trust
is targeting broadly the same value of
CQUIN income in 2015/16.
A new CQUIN framework for 2015-16
has been agreed with our
Commissioners, some of which are
nationally mandated and all of which
are intended to drive improvements in
patient care. All topics will be subject
to incentive payments the level of
which depends on the extent of
achievement.
Topics for 2015-16 include:
dementia
sepsis,
acute kidney injury,
improving prescribing and
dispensing of medication,
increased involvement of
Obstetric Consultant to ensure
appropriateness of all
emergency caesarean
sections
Hydration: safe intravenous
(IV) fluid prescribing.
2.3.5 CQC Registration Compliance
The Royal Berkshire NHS Foundation
Trust is required to register with the
Care Quality Commission (CQC) and
its current registration status is
“Registered without conditions” at its
five registered locations.
31
The Care Quality Commission has not
taken enforcement action against the
Royal Berkshire NHS Foundation
Trust during 2014/15.
CQC Inspections
During 2014/15 Royal Berkshire NHS
Foundation Trust has been subject to
the following visits by the CQC:
The CQC has not undertaken any
inspections in which it has been the
lead regulator in 2014-15 at the Trust.
It will receive the Inspection Report
from Ofsted following a 4-week
inspection of West Berkshire Local
Authority children’s services,
beginning on 4 March 2015, in which
Ofsted is the lead regulator reviewing
arrangements for children in need and
safeguarding provision.
On June 24 2014, the CQC published
the Quality Report of the Trust-wide
inspection it undertook between March
24-26 2014.
The overall rating for the Trust was
requires improvement and the
following ratings were given to the
core services inspected below:
Figure 8: CQC Overall Ratings for RBFT – Inspection June 2014
Accident and emergency
Medical care (including older people’s
care)
Surgery
Intensive/critical care
Maternity and family planning
Services for children and young people
End of life care
Outpatients
With the Quality Report the Trust was issued 7 Compliance Actions (areas in which
the essential standards of quality and safety were not being met) in the following
regulated activities:
32
Figure 9: RBFT CQC Compliance Actions
Regulation
9
Description of
regulation
Care & welfare of people
who use services
16
Safety, availability and
suitability of equipment
17
Respecting and involving
people who use services
Safety and suitability of
premises
15
18
Consent to care and
treatment
22
Staffing
20
Records
Regulated activity
Treatment of disease,
disorder or injury
Surgical procedures
Treatment of disease,
disorder or injury
Diagnostic and screening
procedures
Treatment of disease,
disorder or injury
Treatment of disease,
disorder or injury
Maternity & midwifery
services
Surgical procedures
Maternity & midwifery
services
Treatment of disease,
disorder or injury
Surgical procedures
Maternity & midwifery
services
Treatment of disease,
disorder or injury
CQC Special Reviews
In response to the CQC Report, the
Trust has developed an action plan,
which addresses how we will meet the
requirements of the compliance
actions and other actions specified by
the CQC. Progress of the actions
within the plan is regularly reviewed by
the Trust Quality Assurance and
Learning Committee and externally by
the Clinical Commissioning Group and
the Care Quality Commission. A
number of initiatives have been
implemented to provide assurance to
the Board that the actions have been
delivered, one of which is the Peer
Review Scheme. This involves a
regular programme of
ward/departmental visits to test the
evidence and assess assurance that
improvements have been made.
CQC Outliers
CQC Peer Review
There were no CQC Outlier Alerts in
2014-15.
In January 2015, the Trust started a
programme of internal peer review
visits, the objective of which is to
provide assurance that the issues
The Royal Berkshire NHS Foundation
Trust has not participated in any CQC
special reviews or investigations by
the CQC during the reporting period.
33
identified by the Care Quality
Commission (CQC) in its March 2015
Inspection of the Trust had been
resolved and to celebrate areas of
good practice.
A team of 22 clinical and
administrative staff visit wards and
outpatient areas on an unannounced
basis each month and make
observations and speak to staff about
their knowledge of specific areas of
practice. By early May 2015, 41 visits
will have been made to inpatient wards
and outpatient areas with the following
themes being the focus of each visit:
Dementia, mental capacity act
and deprivation of liberty
awareness and training rates
The maintenance request and
response process
Medical and nursing staffing
levels
The DNACPR process
Sharps practice
Ward based IT provision
Medical equipment provision,
servicing and training
Patient information and access
to translation services
Patient documentation in
medical notes
The results from each visit are fedback to ward staff and management
teams and any Trust-wide action
required as a result of the visits,
identified at the monthly Peer Review
Steering Group chaired by Caroline
Ainslie, Director of Nursing.
In June 2015, a team from the Trust
will be visiting the Royal Bournemouth
& Christchurch Hospitals NHS
Foundation Trust (RBCH) where it will
spend a day undertaking peer review
visits at the Bournemouth Hospital
site. Also in June a team from RBCH
will visit the Royal Berkshire Hospital
site to carry out peer review visits in 10
wards and departments. The aim of
these visits is to give staff at both
Trusts an opportunity use the peer
review skills they have already
developed in making an external
assessment of practice at each
hospital. The days will be a chance for
staff at both Trusts to develop ongoing
relationships with counterparts.
2.3.6 Data Quality
The Royal Berkshire NHS Foundation
Trust 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.
Royal Berkshire NHS Foundation
Trust will be taking the following
actions to improve data quality:
We will be implementing of a new data
warehouse to serve as a centralized
source of Trust information. This is
turn will increase visibility of Trust data
as well as support timely and efficient
tracking of data quality issues across
multiple datasets and sources.
We monitor the accuracy of data in a
number of ways including the Data
Quality Outliers Review group. A
number of workstreams dedicated to
improving data quality (granularity,
timeliness, completeness, validation
and audit) are being planned for
2015/16 these include:
Clinical Coding
Closer clinical engagement
with the coding team is
necessary for increasing the
34
quality of coded information. In
2014/15 significant progress
was made in specialties such
as respiratory medicine where
the impact of improved clinical
engagement can been seen in
recent internal and external
audits. In 2015/16 the Coding
Department would be looking
to work closely with more
specialties is arranging regular
reviews of coded finished
consultant episode (FCE).
In 2015/16 the Coding
Department will be working
closely with the Informatics
Department to track key coding
quality indicators in near real
time. This approach to data
quality is expected to increase
the efficiency of the coding
audit process and will allow us
to review and correct before
external submissions are
made.
Medical Records
We will continue to work
towards improving the content
of its medical records. The
Medical Records Improvement
Programme has been
implemented to coordinate
and drive improvements to our
medical records.
Ward to Board
The Trust has recently
completed the Ward to Board
project which centered on
reviewing the data collection
and assurance process for
reporting of Key Performance
includes Information Quality
Assurance Records (IQARs). In
2015/16 more work is planned to
further implement and embed the
use of the quality assurance
framework in the organisation.
Data Warehouse and Business
Intelligence Reporting
We have begun the
implementation of a new data
warehouse that would serve as
a centralised source of Trust
information; this is turn would
increase visibility of our data as
well as support timely and
efficient tracking of data quality
issues across multiple datasets
and sources.
The implementation of a new
business intelligence solution
will also enable the reporting of
Trust data in near real time, it
is expected that this is turn
would increase visibility and
access of Trust data and
further support a culture of
resolving data quality issues in
a timely fashion and at source.
Improving the quality of external
data submissions
We will continue to engage in a
joint programme of work with our
local CCG (Clinical Commissioning
Group) to triangulate and improve
our data quality. A new joint
programme is also being designed
with NHS England to begin in
2015/16. This will involve
reconciling Secondary Uses
Services (SUS) submissions with
billing (SLAM) to identify areas of
missing or conflicting data.
Indicators (KPIs) from ‘Ward to
Board’, this project has involved
the development of a quality
assurance framework which
35
NHS number and General Medical Practice Code Validity
The Trust provides submissions to the
Secondary Uses System (SUS). This
is a single source of comprehensive
data which enables a range of
reporting and analysis in the UK and is
run by the NHS Information Centre.
The Trust was rated green indicating that the percentages are equal to or greater
than the national rate.
The percentage of records in the published data that included the patient’s valid NHS
number was:
Rating
Accident &
Emergency
care
Admitted
Patient
care
Outpatient
care
% of valid NHS Numbers received
Green
(97.77%)
(99.6%)
(99.8%)
% of valid Medical Practice Codes
Green
(100%)
(100%)
(100%)
The Trust's Information Governance Assessment Report
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 Trust Information
Governance Assessment Report
overall score for 2014/15 was 80%
(2013/14 was 77%) and the grading
was red due to one assessment area
scoring 1.
In 2014/15 72.3% staff received
mandatory training in Information
Governance: 3883 staff received
training; 1492 staff did not receive
training.
Payment by Results Clinical Coding Audit
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.
Royal Berkshire NHS Foundation
Trust was subject to the Payment by
Spells
tested
% of
spells
changing
payment
Clinical Coding
% spells
%
changing
clinical
HRG
codes
Results clinical coding audit during the
reporting period by the Audit
Commission and the error rates
reported in the latest published audit
for that period for diagnoses and
treatment coding (clinical coding) were
10%.
%
diagnoses
incorrect
%
procedures
incorrect
Other data items
% spells % other
with
data
other
items
36
Secondary
Primary
Secondary
Primary
incorrect
data
items
incorrect
incorrect
Audit undertaken in February 2015 by external company – final report not published at time of
publication of this report.
The results should not be extrapolated further than the actual sample audited. The
following services were reviewed within the sample: respiratory and upper
gastronenterology surgery.
37
Part 3: Review of quality performance
Review against 2014/15 quality priorities
In Part 3 of the Quality Account we review quality improvements that we have
delivered throughout 2014/15. We have included actions we need to carry forward
into 2015/16 to ensure our patients continue to receive the best possible care and
experience. The following topics are covered in this section:
Our 6 chosen 2014/15 Quality Account priorities:
Target achieved
Achieved
Achieved
Priority 1 – Patient Safety: Keep patients
safe from Clostridium Difficile infections.
Priority 2 – Patient Safety: Improve harm
free care
Achieved/Improvement Priority 3 – Clinical Effectiveness: Improve
weekend survival rates by reducing the
weekend HSMR
Improvement
achieved)
(nearly Priority 4 –Clinical Effectiveness: Improving
the availability and quality of medical
records
Achieved
Improvement
/ Priority 5 – Patient Experience: Improving
our
courtesy,
communications
and
behaviours.
Improvement
Priority 6 – Patient Experience: Improving
patient
experience
by
reducing
cancellations
1. Other improvements in 2014/15
We prioritised six initiatives for improvement; below we have summarised our
2. Mandated
national
indicators
2014/15
performance
against and
these
indicators.
Progress
has been monitored by the Trust
Board throughout the year and where we have identified further improvement this
has been carried forward to 2015/16 as we recognise that some of our priorities will
take several years to fully implement.
38
Priority 1: Patient Safety: Keep patients safe from
Clostridium Difficile infections.
What did we do?
We continue to reinforce to our staff
the importance of effective hand
hygiene, thorough environmental
cleaning and prompt isolation of
patients who are suspected of having
infectious diarrhoea. This year we
have focused on:The multi-professional West
Berkshire health economy
group reviewing all reportable
cases of Clostridium Difficile
infections (CDI) across acute
and community providers. This
ensured relevant lessons were
learnt promptly and provided a
basis upon which individual
organisations or GP practices
can target further improvement
activity to increase patient
safety
We hosted a Clinical
Commissioning Group
infection control nurse to
ensure effective cross
organisational working
Staff awareness of patient’s
previous history of CDIs to
minimise the risk of CDI
reoccurring from antibiotic
treatment or other patients
being at risk of cross
contamination.
Re emphasising the
importance of hand washing
around the Department of
Health’s standards five
moments of hand hygiene
Ensuring initial empiric therapy
is appropriately modified in
response to microbiological
results
The continued education of
junior doctors and new nursing
staff to minimise the number
of patients acquiring CDI in the
future
39
Did we achieve our target?
Clostridium Difficile
We aimed to have a maximum of 30 CDI cases in 2014/15, improving on our DH
threshold of 40. We achieved 29 CDI cases (end March 2015).
Figure 10: RBFT Trust Acquired Clostridium Difficile 2014-15
40
Priority 2: Patient Safety: Improve harm free care
What did we do?
Pressure Ulcers
Our Pressure Ulcer Steering Group
oversees the pressure ulcer
prevention and management work
programme, in 2014-15 this included:
We employed a senior staff
nurse to join the Tissue
Viability Team. Her role is to
review all patients with a Trust
acquired pressure ulcer and
ensure that the ward staff have
commenced the patient on the
pressure ulcer prevention and
management care pathway.
This nurse undertakes spot
audits on individual wards
application of the care
pathway, reported these results
to the ward sister and matrons.
Where necessary the post
holder delivers ward based
training to ensure that the staff
have the knowledge and skills
in pressure ulcer prevention
and management.
We reviewed our pressure
relieving mattress provision to
ensure that the Trust had
enough equipment. To cope
with higher demand in
December and January this
included hiring an additional 45
pressure relieving mattresses.
Falls
Our Falls Steering Group oversees the
falls prevention and management work
programme, in 2014-15 this included:
Implementation of a Trust-wide
action plan to address themes
Ward specific action plans
All falls where harm is
sustained were assessed
whether they are avoidable or
unavoidable
Revised our Root Cause
Analysis (RCA) tool to ensure
all contributing factors
appropriately identified
Fall champions have been
appointed and have received
falls training
Education and falls awareness
programmes have been linked
to dementia training
Risk assessments are
undertaken for all inpatients
with appropriate prophylaxis
prescribed
We have implemented a
validation process to review
patients who have been
The Catheter Associated Infection
Quality Improvement project group
have been reviewing and making
improvements in the following areas:
The need for catheterisation
Selecting the appropriate
catheter type
Venous thrombo embolism (VTE)
identified in the Safety
Thermometer as being treated
for VTE prior or post admission
Urinary tract infections following
urinary catheters insertion (Cat UTI)
Catheter insertion and aseptic
technique
Urinary catheter management
Working with Berkshire
Healthcare NHS Foundation
Trust
Education for patients and
families
41
Appropriate equipment
selection
Did we achieve our target?
Harm free care
Our aim was to achieve 95% “harm
free care” (as measured by incidence
of all harms) and 98.5% (as measured
by the Department of Health Safety
Thermometer). The patient safety
thermometer captures harms which
have occurred prior to admission as
well as new harms which have
occurred since admission
The four areas of harm measured by
the patient safety thermometer:
Pressure ulcers – identifies
pressure ulcers that were
present when the patient was
admitted or hospital acquired
Falls – identifies all falls the
patient has experienced within
72 hours of the survey being
performed
Venous thrombo-embolism
(VTE) – identifies patients who
are being treated for a VTE
(deep vein thrombosis,
pulmonary embolism)
Urinary tract infections
following urinary catheters
insertion – identifies patients
who have a urinary catheter in
place within 72 hours of the
survey taking place and any
patient being treated for a
urinary tract infection (UTI)
Whilst for quarter 1, 2 and 3 we have
not achieved the target of 95% harm
free care we were above the national
average in 10 of 12 months during
2014/15 and we achieved the 95% for
every month in quarter 4.
We have met the target of 98.5 % in
new harms for 6 months of the year.
Constant vigilance is required to
maintain this level of performance as
the operational challenges related to
capacity and staffing levels continue to
escalate.
42
Figure 11: RBFT Safety Thermometer Performance against the harm free targets (All
harm free and New harm free)
99%
Safety Thermometer - Performance vs
Target
97%
95%
93%
91%
All harm free care target
New harm free target
All harm free care actual
New harm free care actual
The table below summarises the national percentage of harm free care from the
period of April 2014- March 2015.
Figure 12: RBFT Performance in Department of Health Safety Thermometer 2014-15
Month
Apr
May
Jun
July
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
% new harm free
National Average
93.5
%
93.6
%
93.6
%
93.8
%
93.7
%
93.8
%
94.0
%
93.9
%
94.1
%
93.9
%
93.8
%
94.0
%
% new harm free
RBFT
98.3
5
99.0
7
98.6
6
98.3
7
97.9
98.1
2
98.3
98.5
5
99.2
2
99.0
3
99.2
2
98.2
5
All harm free%
93.5
6
94.2
8
95.2
9
95.6
93.1
8
93.3
3
93.0
3
96.1
3
94.5
7
95.3
1
95.4
5
95.5
3
Old PU%
3.8
3.55
2.69
2.61
3.5
3.25
4.08
2.26
4.04
3.07
3.77
2.55
New PU%
0.17
0.46
0.5
0.33
0.17
0.34
0.17
0.81
0.16
0.16
0.31
0.32
New VTE%
0.66
0.31
0.17
0.16
0.35
1.2
0.17
0.16
0.16
0.65
0.16
0.32
0.5
0
0.5
0.65
1.22
0.34
0.85
0.48
0.47
0.16
0.16
0.8
All harm free care
target
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
All harm free care
actual
93.5
6%
94.2
8%
95.2
9%
95.6
0%
93.1
8%
93.3
3%
93.0
3%
96.1
3%
94.5
7%
95.3
1%
95.4
5%
95.5
3%
New harm free
target
98.5
0%
98.5
0%
98.5
0%
98.5
0%
98.5
0%
98.5
0%
98.5
0%
98.5
0%
98.5
0%
98.5
0%
98.5
0%
98.5
0%
New harm free care
actual
98.3
5%
99.0
7%
98.6
6%
98.3
7%
97.9
0%
98.1
2%
98.3
0%
98.5
5%
99.2
2%
99.0
3%
99.2
2%
98.2
5%
Catheter & new UTI
43
Severe Harm Falls: The Trust has continued to demonstrate improved
performance with falls prevention. There were 20 high harm falls this year
compared to 28 last year. Of the 20 falls root cause analysis has determined
that 9 of these were unavoidable. Learning from avoidable falls has been
incorporated into the falls action plan.
Pressure Ulcers: There were no grade 3 or 4 hospital acquired pressure
ulcers were reported in March. There were a total of 5 pressure ulcers
reported over the financial year, however 1 was downgraded. The Trust has
met the quality target for this year of reporting no more than 4 (grade 3 or 4)
avoidable pressure ulcers. This compares to a total of 20 for the previous
financial year.
Figure 13: RBFT Pressure Ulcer performance April 2013 – March 2015: reported grade 3
and 4 pressure ulcers
RBFT Reported Grade 3/4 Pressure Ulcers
April 2013 - March 2015
5
4
2013-14
3
2014-15
2
1
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
44
Figure 14: RBFT Pressure Ulcer performance August 2014 to March 2015: reported
grade 2 pressure ulcers
45
Priority 3: Clinical Effectiveness: Improve weekend
survival rates by reducing the weekend HSMR harm free
care
What is HSMR?
What did we do?
Hospital Standardised
Mortality Ratio (HSMR)
compares the number of
deaths at each hospital in
England and is a measure of
quality. A score of 100
represents “an expected” level
of deaths, a score lower than
100 represents “less than
expected” deaths and a score
of more than 100 “more than
expected” deaths. An
independent company Dr
Foster Intelligence collates
and reports HSMR
We developed and continue to embed our quality
improvement programmes for pneumonia, acute
kidney injury (AKI), sepsis, theatre safety and
delivering seven day working. We reviewed and
continue to review patient deaths on a regular
basis to identify to learn from potentially avoidable
deaths. We are one of the leading trusts
participating in the Sign up To Safety national
campaign announced in June 2014. We have
developed our strategic implementation plan to
launch Trust wide in April 2015 with a focus in 6
key safety areas (never events, AKI, sepsis, right
information, medication safety and addressing
events that lead to clinical negligence claims).
Sepsis prevention and management
We have developed a sepsis
identification tool. This tool advises
staff to assume sepsis until otherwise
demonstrated. The tool prompts staff
to identify sepsis by using the
Systemic Inflammatory Response
Syndrome (SIRS) criteria, identifying a
source of infection and signs of organ
dysfunction. The sepsis identification
tool informs staff to start the clock and
complete intra venous Antibiotics,
Fluid therapy, Oxygen, blood Cultures,
Urine output, Serum lactate (AFOCUS
management tool) within one hour.
This is also highlighted to refer to
critical care and outreach teams. We
have worked with medical
photography and clinical skills to
develop a video to educate all nursing
staff how to take a venous blood gas
to enable faster lactate analysis and
diagnosis.
From September 2013-September
2014 a Sepsis Senior Staff Nurse was
employed to provide sepsis education
to staff in the Trust
We have provided all wards with a
“Sepsis Pink Pump” which is an
emergency piece of equipment to be
used if a patient develops sepsis. This
avoids delays in waiting for porters to
bring a pump to the ward therefore
allowing IV Antibiotics to be giving
within the hour once prescribed.
We worked closely with the sepsis
champions throughout the Trust to
give regular updates via emails and
bimonthly meetings assisting them as
required.
The Trust has developed a Sepsis
action plan to improve both sepsis
antibiotic administration and sepsis
screening outcomes from our current
baseline to improve performance
during 2015. This is also part our
commitment National Sign up to
Safety campaign where we seek to
reduce avoidable harm by 50% by
46
2017. The Quality Improvement team
together with the Trust Sepsis Group
and other multidisciplinary groups will
implement the sepsis action plan with
regards to:
The recognition and
assessment of sepsis
Ongoing educational
awareness for all hospital staff
to raise awareness of sepsis
care, through our sepsis
master class training
Implementation and
monitoring of the national
CQUIN recommendations for
sepsis
Implement best Practice
Benchmark in the treatment of
inpatient sepsis through Dr
Foster Global Comparators
Score card
Did we achieve our target?
Our aim was to reduce our weekend Hospital Standardised Mortality Radio (HMSR)
to the national benchmark of 100 or less by March 2015 and we have achieved a
sustained and stable improvement over the year. Our weekend HSMR December
2013-November 2014 (the latest benchmarked data) is 89.4 and for weekends is
93.3 thus achieving our target. At the time of writing this report data from quarter 4 is
not available as reports are received 3 months in arrears; we will continue to monitor
this target.
This Year
Mortality
Indicator
s
Ap
r
Ma
y
Ju
n
Jul
y
Au
g
81
.1
1
73.4
3
Se
pt
De
c
Ja
n
Fe
b
Ma
r
Tar
get
So
urc
e
Outturn
201
3/14
O
ct
Nov
89
.3
0
87.
80
89.4
0
10
0
Nati
onal
Ave
87.1
5
Q4
YT
D
Tar
get/
Thr
esh
old
201
4/15
HSMR 12
months
rolling
weekdays
HSMR 12
months
rolling
weekend
HSMR 12
months
rolling all
days
96.
63
90
.3
7
94
.3
5
98.3
3
99
.8
0
94.
50
93.8
0
10
0
Nati
onal
Ave
96.6
3
89.
21
83
.9
5
82
.8
3
85.2
2
92
.3
0
89.
00
90.2
0
10
0
Nati
onal
Ave
89.2
1
HSMR
weekdays
79.
51
86.3
0
10
0
82.
96
84
.7
0
99
.2
4
86
.9
7
87.
80
HSMR
weekend
77
.2
6
94
.8
2
58.
30
108.
10
10
0
74.
90
91.9
0
10
0
HSMR
all days
72.5
2
96.7
6
80.9
6
97
.6
0
11
3.
90
10
2.
20
N/A
Nati
onal
Ave
Nati
onal
Ave
Nati
onal
Ave
83.5
2
64.8
0
78.5
0
47
Figure 15: RBFT Hospital Standardised Mortality Ration (HSMR) January 2014 to
December 2014 - weekends
Figure 16: RBFT Hospital Standardised Mortality Ration (HSMR) January 2014 to
December 2014
48
Sepsis
We build on improvements that our “Surviving Sepsis Campaign” achieved in
2014/15. It was our aim that 90% of all patients admitted to the Emergency
Department with a suspicion of infection would receive antibiotics within one hour.
Whilst we made improvements in this area our quarter 4 achievement was 52.4%
and we have work to do in order to achieve our target. This target is one that has
now been set as a national CQUIN for all acute trusts by NHS England for 2015/16
and this priority will continue, progress will be overseen internally as well as by our
commissioners.
49
Priority 4: Clinical Effectiveness: Improving the availability
and quality of medical records
What did we do?
We have:
Made changes to the way in
which records are delivered to
Outpatient Clinics to improve
availability.
Identified 32 ‘Champions’ from
various staff groups across the
Trust to help communicate and
support the need for
improvement with their peers.
We have developed of Key
Performance Indicators (KPIs)
Security of Records Audit 97 areas have been audited covering
inpatients, outpatient clinics and admin
offices. Activities reviewed included
security & access, storage, processing
& practice, IT governance, tracking
and information governance
awareness.
to enable monitoring of
progress going forwards.
Completed a feasibility study
completed for implementation
of electronic tagging to improve
storage and availability of
records.
We undertook two main reviews that
helped us understand the extent of the
problem with regard to records
management (see review of priorities
for full detail)
Initial findings indicated that the
majority of areas are low to medium
risk and relating to behaviours/ways of
working, records management training
and information governance, storage
and staff. There were three high risk
areas that require immediate action.
Quality of Content Audit Our 2014 Quality of Content Audit highlighted that although there has been an
improvement in some areas, the quality of medical records was still below the
standards we require.
50
Figure 17: RBFT Medical Records Quality of Content Audit 2014
Quality of Content 2014-15 Audit Preliminary Findings
No. Question
2013 / 14
2014 / 15
1
2
3
4
5
6
Is the whole healthcare record in chronological order?
Is the outer covering of the healthcare record intact?
Does each page of the notes have an addressograph (or patient name/DOB/NHS no)
Does each page of the notes have the location on the page?
Was EDL printed off and filed in the notes?
Was there evidence of the discharge planning summary being started after admission?
45%
80%
13%
Not asked
68%
79%
92%
16%
8%
90%
28%
57%
Question
2013 / 14
Doctors
Nurses
Therapists
96%
79%
79%
82%
Not asked
61%
717
100%
97%
83%
97%
72%
56%
710
99%
88%
78%
98%
NA?
37%
289
100%
99%
86%
100%
NA?
92%
Q
No
7
8
9
10
11
12
13
No
17
18
19
20
21
Total number of entries reviewed
Number of entries in blue/ black ink?
Number of entries with date recorded
Number of entries with time recorded
Number of legible entries
Number of entries with bleep recorded
Number of entries with a clear signature that identifies the author
Question
VTE Prophylaxis administered
No of entries on drug chart reviewed
Drug chart includes prescriber’s signature and date
Drug chart includes date when treatment is started
Drug chart cancellations should be legibly crossed off, dated and signed by doctor
making the change
2013 / 14
70%
99%
100%
67%
22
Drug chart IV antibiotics MUST be reviewed every 48 hours and documented
74%
23
24
Drug chart times of administration recorded
Allergy status recorded
74%
86%
2014 / 15
63%
818
99%
97%
Data to be
reviewed
Data to be
reviewed
96%
65%
*Green= improvement from 2013/14 Red = results are worse than previous audit
An action plan is in place to address these issues during 2015/16 – see review of
priorities on pages 15-16 of this report.
Did we achieve our target?
In 2014/15 our target was to improve
availability of medical records in
outpatients before time of
appointments from 96% to 98% by
March 2015.
An audit of 80 outpatient clinics in
August demonstrated that 97.8% of
records were present and available at
the time of the patient’s appointment.
The next stage is to increase the
availability of records to be available in
clinic by 2pm prior to the day of
appointment.
We achieved our aim of having a
detailed improvement plan was in
place by June 2014.
We also had the target of a step
change in performance reducing
unavailable notes by 50% on 2013/14
performance.
51
Priority 5: Patient Experience: Improving our courtesy,
communications and behaviours
We are committed to listening to the views of patients and members of the public in
the form of complaints, concerns, comments and compliments and using this
information as a means of addressing issues and improving and developing the
quality of the services we provide.
The Patient Relations Team deal with issues and concerns as soon as they arise, in
order to try and remedy the situation as soon as possible, where this is not possible,
they take a proactive role in managing the complaints received by the Trust.
What did we do?
Every written complaint received which related to negative staff behaviour was
reviewed in line with the process and the relevant manager was asked to investigate.
A new process for dealing with complaints received relating to staff behaviour and
attitude has been implemented.
Patient Relations Team
Complaint received relating to staff behaviour/attitude
First complaint for this staff member
Logged with PRT and investigation completed
Second complaint for
this staff member within
six months
Third complaint for this
staff member within six
months
Follow process for
first complaint
received
Follow process for
first complaint
received
Staff member to be
supported to seek
coaching**
Formal performance
management to be
instigated
Complaint well founded?
Yes
No - End
Statement from staff member must
provide assurance that reflection has
been undertaken and discussed with
line manager
If relates to medical staff copy of
complaint and final response
shared with Medical Director
Complaints training
51 people undertook complaints
training in 2014/15
The objective of the training is to
provide participants with the key skills
to effectively improve their handling of
52
patient complaints. During the one day
programme, delegates;
Gain a better understanding of
their role within the complaints
process and of the benefits of
complaints
Recognise the qualities needed
to handle patient complaints
Discover how to build rapport
and engage with the patient
Demonstrate empathy whilst
maintaining control of the
conversation
Establish the patient’s needs
through questions and listening
Defuse difficult patient
emotional responses
Understand the use of positive
and responsive language and
adopting ‘Plain English’ in both
written and verbal
communication
Apply their learning to their own
complaint situation
We are currently evaluating feedback
from the training and review the
content of training. We intend to run
further sessions in 2015/2016.
Hello My Name is Campaign
This year we launched the #hello my
name is campaign to improve the
communication between patients and
staff. #hello my name was established
by doctor and cancer sufferer Kate
Granger. Kate was surprised at the
number of staff she came into contact
with during her treatment who did not
introduce themselves. It is a simple
change that can make a huge
difference to our patients’ experience.
The launch event was attended by
members of our board, doctors,
nurses, physiotherapists, and admin
staff.
The Hello My Name is Launch
53
Did we achieve our target?
We aimed to increase from 70 to 75 the net promoter score from patients. In
December 2014 all NHS Trusts moved from completing the Net Promoter Score to
completing the Friends and Family test: The NHS England review of the patient FFT,
published in July 2014, recommended a move away from the Net Promoter Score
(NPS) and the introduction of a simpler scoring system in order to increase the
relevance of the FFT data for NHS staff, patients and members of the public. Based
on the findings of the review, NHS England is now calculating and presenting the
FFT results as a percentage of respondents who would/would not recommend the
service to their friends and family. This change was introduced in the first publication
of Staff FFT results on 25 September 2014 and across all existing patient FFT
settings on 2 October 2014.
We consider we achieved this target:
Figure 18: RBFT Friends and Family Recommendation Ratings December
March 2015
(Trust Internal
Rolling Survey)
2012/13
score (Trust
internal
rolling
monthly
survey)
2013/14
Patients who would recommend this
hospital to family and friends
96%
97%
98%
Rating Care as “Good”, “Very Good”
or “Excellent”
96%
96%
98%
84%
81%
89%
Question
(subset rating care as “Very
Good” or “Excellent”)
( Trust
Internal
Rolling
monthly
survey)
54
Complaints
Whilst we failed to reduce the percentage of complaints relating to attitude and
behaviour we have made improvements to our processes for handling complaints
and to our response times.
Figure 19 2014-February 2015
RBFT Complaints about behaviour 2014-15
Complaints
about
behaviour
and
attitude
10
5
5
4
6
8
11
5
7
5
4
4
13
74
39
Contract
70
Number of
Complaints
44
34
29
38
33
38
39
43
26
30
37
42
109
433
400
Contract
422
35
29
28
28
27
27
26
26
26
26
26
26
28
3days
Contract
N/A
233
278
296
280
241
309
337
265
252
241
235
733
3224
3000
Local
2982
Complaints
average
response
time
Number of
PALS
concerns
26
257
25
Figure 20: RBFT Complaints Performance Communication complaints breakdown by
sub-subject
2012/2013
2013/2014
2014/15
Behaviour and attitude
67
77
74
Inadequate information
21
18
22
Lack of information
18
18
8
Patient not listened to/heard
14
7
10
Conflicting information
8
6
4
Incorrect information
8
7
8
Breaking bad news
7
3
2
Breach of confidentiality
3
0
5
Referral between directorate
1
1
0
147
138
133
Total
55
Figure 21: RBFT Complaints Performance Average number of day to close per month
for each Care Group 2014-15
We have significantly improved the timeliness and quality of our complaint
responses.
Trust
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
35
24
27
25
23
26
24
23
26
28
30
21
Networked Planned Urgent
16
28
49
19
26
23
23
31
23
20
36
18
19
31
14
19
33
22
19
27
21
19
23
24
21
27
25
16
35
26
17
32
29
20
18
25
56
Priority 6: Patient Experience: Improve patient experience
by reducing cancellations
Cancelled operations
What did we do?
The Trust theatre management team has continued with the project to improve the
efficiency of our operating theatres, which includes reducing the number of
operations cancelled on the day of surgery for non clinical reasons.
Did we achieve our target?
We aimed to continue to reduce the cancellation of operations on the day for both clinical
and non clinical reasons to 0.5% which is an improvement of 0.2% on 2013/14 out turn.
The national target is <0.8%. This has proved extremely challenging. The year to
date performance stands at 0.7% with no significant difference from last year.
Figure 22: RBFT Operations Cancelled for Non Clinical Reasons
OutTarget/
Inpatient
Ma
YT
turn
Apr May Jun July Aug Sept Oct Nov Dec Jan Feb
Q4
Threshol
s
r
D
2013/1
d 2014/15
4
Operation
s
cancelled
by the
0.9
hospital
0.6% 0.7% 0.4% 0.9% 0.6% 0.7% 0.3% 0.8% 1.4% 0.9% 0.5%
0.8% 0.7% 0.5%
%
on the day
of surgery
for nonclinical
reasons
Cancelled
operations
0.00 0.00 0.00 6.06 10.53 8.70 0.00 0.00 11.09 5.41 15.79 no 10.6
not re5.2% 5.0%
%
%
%
%
%
%
%
%
%
%
data %
scheduled %
within 28
days
A number of issues have resulted in
this performance. At the beginning of
the year there were issues with
medical staff sickness and estates.
Following resolution performance
improved through Quarter 2. The
initiatives in place proved successful.
However from October we have been
0.55%
4.78%
challenged with the emergency access
clinical standard impacting on patients
cancelled due to there being no bed
available. This had a significant
impact on the reversal in performance
through Quarter 3 as shown below in
the graph which has excluded this
category.
57
Figure 23: RBFT Cancelled Operations, breaches and rebooked within 28 days
Apr14
May14
Jun14
Q1
Jul14
Aug14
Sep14
Q2
Oct14
Nov14
Dec14
Q3
Jan15
Feb15
Mar15
Q4
YTD
Cancelled All
Ops
Elective
%
Last
min
28 day
breaches
20
3,389
0.59% 99.41% 0
0.00% 100.00%
16
80.00%
25
3,529
0.71% 99.29% 0
0.00% 100.00%
23
92.00%
16
3,674
0.44% 99.56% 0
0.00% 100.00%
15
93.75%
61
10,592
0.58% 99.42% 0
0.00% 100.00%
54
88.52%
33
3,654
0.90% 99.10% 2
6.06% 93.94%
32
96.97%
19
3,170
0.60% 99.40% 2
10.53% 89.47%
14
73.68%
23
3,511
0.66% 99.34% 2
8.70% 91.30%
21
91.30%
75
10,335
0.73% 99.27% 6
8.00% 92.00%
67
89.33%
14
4,111
0.34% 99.66% 0
0.00% 100.00%
14
100.00%
30
3,845
0.78% 99.22% 0
0.00% 100.00%
27
90.00%
36
3,033
1.19% 98.81% 5
13.89% 86.11%
0
0.00%
80
10,989
0.73% 99.27% 5
6.25% 93.75%
41
51.25%
37
3,956
0.94% 99.06% 2
5.41% 94.59%
0
0.00%
18
3,875
0.46% 99.54% 1
5.56% 94.44%
0
0.00%
34
4,418
0.77% 99.23% 3
8.82% 91.18%
0
0.00%
89
305
12,249
44,165
0.73% 99.27% 6
0.69% 99.31% 17
6.74% 93.26%
5.57% 94.43%
0
162
0.00%
53.11%
We are working with an external team
to improve efficiency Workstreams
include, pre-op, consent, list
%
rebooked in 28
days for PCT
Rebooked in Rebooked in 5
5 days
days %
organisation, enhanced recovery and
a bed booking system aligned to
theatre lists. This work will continue
through 2015-16.
Rescheduled Outpatient Appointments
What did we do?
In addition to the Quality Account
target our Trust’s Improvement Board
set a target to reduce the number of
clinic appointments that were
rescheduled to <9% of all
appointments. A number of actions
have been undertaken in identifying
the reasons why appointments are
rescheduled. In May cases these
cancellations are legitimate, for
example, on clinical review the referral
is moved to another consultant or the
patient is discharged. However we
recognise the largest cause of the non
legitimate cancellations is due to late
notice cancellations of clinics that have
already been booked.
58
Did we achieve our target?
Analysis of performance shows that
during 2014-15 Quarter 2 and Quarter
3 had a performance of 10%. This is a
marked improvement of the previous
year. The first 2 months of Q4 show
further improvement.
Figure 24: RBFT Cancelled and Scheduled Appointments 2014-15
Date Range
Appts Made
Appts cancelled & rescheduled Appointments cancelled due to Admin
No.
%
No.
%
6,241
1,896
3%
3%
3%
2,108
3%
July - Sept 2014
199,345
14,776
Oct - Dec 2014
206,449
13,619
Jan-15
62,327
6,568
7%
7%
6%
Feb-15
6,233
3,983
6%
We aimed to have sustained reduction in
the waiting times for first outpatient
appointments to less than 6 weeks for all
specialties. The current waiting times
are listed below. The specialties are
working with the NHS Intensive
Support team to implement the IST
capacity and demand model (a model
that helps us to understand inpatient
demand, variation by service/specialty
and capacity levels to deliver a
service).
We aimed to improve the waiting times
for an outpatient appointment in
ophthalmology to a maximum of 6
weeks for a first appointment which is an
improvement of 4 weeks when
compared to performance in 2013/14.
7,016
Total
%
10%
10%
9%
9%
For Ophthalmology the waiting time for
first outpatient appointment is 7.33
weeks, further improvement is needed.
This will provide the teams with the
information to put in place the correct
capacity based on demand with a
target waiting time. All specialties are
expected to have waiting times at less
than 6 weeks within 2015-16; this will
remain a target for 2015-16.
The reduced waiting times are key to
reducing rescheduling. By
implementing a robust process of
notification of cancelling clinics at 8
weeks or longer alongside the shorter
waiting times there will be fewer
requirements to reschedule.
59
Figure 25: RBFT Average Waiting Times at March 2015
Specialty
CARDIOLOGY
COMMUNITY PAEDIATRICS
GASTROENTEROLOGY
OBSTETRICS
PAEDIATRICS
RESPIRATORY MEDICINE
RESPIRATORY PHYSIOLOGY
STROKE MEDICINE
BREAST SURGERY
CLINICAL ONCOLOGY
COLORECTAL SURGERY
DENTAL MEDICINE SPECIALTIES
ENT
GENERAL SURGERY
GYNAECOLOGY
MAXILLO-FACIAL SURGERY
OPHTHALMOLOGY
ORAL SURGERY
ORTHODONTICS
PLASTIC SURGERY
TRAUMA & ORTHOPAEDICS
UPPER G I
UROLOGY
VASCULAR SURGERY
AUDIOLOGICAL MEDICINE
CLINICAL HAEMATOLOGY
GENITOURINARY MEDICINE
GERIATRIC MEDICINE
NEPHROLOGY
NEUROLOGY
PAIN MANAGEMENT
TRUST TOTAL
Average Waits
(weeks)
5.46
6.00
6.69
4.13
7.98
8.34
5.35
10.65
2.90
3.96
6.28
3.50
9.04
6.28
5.42
12.21
7.33
7.58
10.18
4.70
4.43
5.94
7.09
5.93
2.92
6.06
8.38
7.63
7.59
9.71
7.78
7.32
60
Other achievements and improvements we made in
2014/15
We undertook a range of work during 2014-15 to improve our services:
Trust Improvement Programme
We have developed our Quality Governance Structure and have a Trust
Improvement Programme Steering Group which oversees our key improvement
projects.
Figure 26: Royal Berkshire NHS Foundation Improvement Programme Board structure
61
Quality Committee Structure
Figure 27: Royal Berkshire NHS Foundation Trust Quality Committee Structure
Sign up to Safety
We are one of the first 12 NHS
organisations that have committed to
Sign Up For Safety. Sign up to
Safety’s 3 year objective is
to reduce avoidable harm by 50%
and save 6,000 lives by June 2017.
Our commitment statement June
2014
The key areas that our Trust sees as a
priority of patient safety improvement
are never events, sepsis, medication
errors, medical records, clostridium
difficile, acute kidney injury and
pneumonia. Sign up to Safety will help
provide a focus for our priorities but is
also an exciting and
valuable opportunity to share best
practice and learn from, and be
supported by, others. We want
to stretch ourselves to improve and
transform, embedding a culture of
patient safety and continuous
improvement. It will also be an impetus
to aligning the work of the Patient
Safety Federation (RBFT is host
organisation) and the (future) Patient
Safety Collaborative. There is the
potential for innovative practice but at
the same time Sign Up to Safety will
really enable us to build on work we
are already doing with a robust plan of
improvement action.
What is Sign Up to Safety?
62
Sign up to Safety is an NHS England
campaign designed to help realise the
ambition of making the NHS the safest
healthcare system in the world by
creating a system devoted to
continuous learning and improvement.
This ambition is bigger than any
individual or organisation and
achieving it requires us all to unite
behind this common purpose.
Sign up to Safety aims to deliver harm
free care for every patient, every time,
everywhere. It champions openness
and honesty and supports everyone to
improve the safety of patients.
Figure 28: Sign Up To Safety Campaign Pledges
Organisations and individuals who sign up to the campaign commit to
setting out actions they will undertake in response to the five safety pledges:
1. Put safety first. Commit to reduce avoidable harm in the NHS by half
and make public the goals and plans developed locally.
2. Continually learn. Make their organisations more resilient to risks, by
acting on the feedback from patients and by constantly measuring and
monitoring how safe their services are.
3. Honesty. Be transparent with people about their progress to tackle
patient safety issues and support staff to be candid with patients and their
families if something goes wrong.
CHKS
4. Collaborate. Take a leading role in supporting local collaborative
learning, so that improvements are made across all of the local services
that patients use.
5. Support. Help people understand why things go wrong and how to put
them right. Give staff the time and support to improve and celebrate the
progress.
CHKS Top 40 Hospitals
We were named as one of the CHKS
Top 40 Hospitals of 2014. These
awards recognise top performing
trusts and are based on the evaluation
of 22 indicators of clinical
effectiveness, health outcomes,
efficiency, patient experience and
quality of care.
63
Staff engagement / Staff survey
NHS Staff Survey results 2014
For the 2014 national NHS Staff
Survey we received 2,032 completed
surveys.
This gives us a valuable insight into
how staff think we perform as a place
to work and receive treatment.
How do we compare to other
trusts?
We were proud that we are in the top
20% of trusts for:
Staff motivation
Feeling satisfied with the quality of
work and patient care you are able
to deliver
Agreeing that your role makes a
difference to patients
Feeling secure to raise concerns
about unsafe clinical practice
Feeling that your role makes a
difference to patients
Having equality and diversity
training in last 12 months
Agreeing feedback from patients is
used to make informed decisions
by your department.
We also performed better than the
national average in a number of other
areas including:
Staff engagement
o You feel that you can
contribute towards
improvements at work
o You recommend us as a place
to work or receive treatment
o You are motivated at work.
Job satisfaction
Well-structured appraisals
Feeling able to contribute towards
improvements
Work-related stress
Support from line managers
Receiving health and safety
training.
What we have we improved on
since last year’s survey?
This year more of staff reported having
had health and safety training, and
equality and diversity training in the
last 12 months.
Where are we doing worse than
other trusts?
While we are performing well in some
important areas, we recognise we
need to improve on:
We perform worse than average in:
Reporting errors, near misses or
incidents witnessed in the last
month
Experiencing discrimination at
work in last 12 months
Believing the Trust provides equal
opportunities for career
progression.
Where are we performing worse
than last year’s survey?
More staff reported that they:
Feel work pressure
Experience harassment, bullying or
abuse from other staff.
What have we done with you
feedback from the last survey?
Staff feedback from the last survey
placed us in the best 20% of acute
trusts in a number of areas including
your recommendation of the Trust as a
place to work or receive treatment. But
there were things that we needed to
improve on.
Staff said that on the front line you
were working harder and for longer
hours.
64
What did we do about it?
Quality improvement projects to
reduce inefficiencies and waste, and
supporting staff to work smarter not
harder
Worked hard to manage
challenges around capacity and we
continue to have nursing
recruitment drives
We supported initiatives such as
the Schwartz Centre Rounds - a
forum for hospital staff from all
disciplines to discuss difficult
emotional and social issues that
arise in caring for patients
Introduced more staff benefits so
you can access initiatives such as
loans for bikes, computers, mobile
phones and cars.
Nursing recruitment and skill
mix
The National Quality Board advocates
a twice yearly review of nurse staffing
levels, with public Board level
discussion to ratify and agree nurse
staffing levels.
Ward staffing levels were reviewed in
July 2014 and January 2015 using a
triangulated methodology; nationally
recommended Safer Nursing Care
Tool, triangulated with professional
judgement, benchmarking and nurse
Staff said that they had not received
health and safety training.
What did we do about it?
We made it a priority for all staff
coming into the organisation and
existing staff have the appropriate
training – from manual handling to fire
safety. Now we are performing better
than most other trusts in this area.
What are we doing with this year’s
feedback?
Our Executive Director of Workforce
and Organisational Development will
use this year’s staff survey feedback
and the feedback provided in the staff
listening exercises to develop an
Organisational Development Strategy
for the Trust. The strategy will aim to
improve our culture to make the Trust
an even better place to work and
receive care.
sensitive indicators. A set of core
principles were established to ensure
consistency across all wards included
in the review.
Outcomes from the review are
presented and agreed at the Trust
Board Resources committee.
On a monthly basis the Board
receives a report outlining actual staff
on duty on a shift by shift basis versus
establishment levels for the previous
month. This data is published on the
Trust website and uploaded on NHS
choices webpage.
HSJ Best Places to Work (Sept 2014)
We were recognised as one of the
best places to work by the Health
Service Journal (HSJ).
We employ a total workforce of 4,642
highly motivated people, three
quarters of whom would recommend
65
our Trust as a place to work and
believe they can contribute towards
improvements within the organisation.
We will be hoping to maintain the low
stress levels and work pressure felt by
staff (2.88 out of 5).
Implemented the Francis Report Action Plan
We took a consultative Trust-wide
approach to the Francis Report
recommendations. A high level
‘Francis Steering Group’ lead by the
Medical Director and the Executive
Director of Nursing reviewed the
recommendations and considered that
100 recommendations were relevant
under a number of themes, below.
Progress against these is set out in the
following pages.
• Quality information
reporting and escalation
• Board leadership
• Complaints
• Mortality: certification
and inquests relating to
hospital death
• Patient and public
involvement and
engagement
• Culture and values:
openness and candour
• Nursing, Medical
training and education
• Care of the elderly
Structured listening exercise
In February 2015 structured listening
exercises took place across the
organisation. Individual or small group
discussions around a pre-set
questionnaire were held with staff.
Discussions were held with samples of
staff – from all clinical and non clinical
(corporate) areas. In addition to this
there were open forum events and
staff could also complete a survey
online. Feedback was received from
over 800 staff.
Since the Francis report the Trust has
progressed a number of significant
improvement work streams including
the Quality and Patient Engagement
Strategies; the Quality Governance
Framework, Board development;
Board to Ward reporting; and the
nursing skill mix review.
Although improvement continues in all
areas, there are three themes above
that we know we need to make more
progress and more effort. These
have and continue to form the focus of
our on-going improvement work:
• Information/data use
and sharing
• Culture and values
• Handling and
addressing complaints
The Francis Report action plan was
implemented, with key actions having
been completed; some actions were
devolved for Care Groups to
implement.
Staff appreciated being “listened” to;
and the opportunity to express their
views. Staff reporting feeling happy
with their immediate managers and
feeling engaged within their local
teams. Staff reported feeling a need to
improve the level of engagement with
staff above their immediate level.
Some staff reported feeling concerned
about staffing levels. Leadership
visibility and communication from
leadership was felt to have improved
since last year in some areas.
Staffvalue the CEO briefing sessions
and the weekly ‘Round-Up’ (electronic
Trust staff newsletter).
66
A&E Performance
There has been intense pressure on
many Emergency Department’s (ED)
across the UK this winter and we have
been no exception. We have worked
hard to improve patient access. We
achieved a recovery in mid-January, a
decline in performance in February
and minimal variance in March. Whilst
the Trust has not achieved the 95%
compliance we have performed
favourably compared with Trusts
across the country through the winter
period.
Figure 29: Regional Accident and Emergency Weekly Performance 4 January 2015 to 5
April 2015
We have undertaken the following actions to achieve this:
Setting and delivering operational standards within the key areas; ED/
Ambulatory / GP unit / AMU/ Short Stay to ensure right patient, right
place right time.
The Emergency Surgical Unit has been established within Hunter
ward following a successful pilot
The Trust have commenced a patient flow programme;
o Surgical ambulatory
o Improved same day
o Discharge processes
Review out of hours medical cover to respond to the evening flow from
GPs
Work with the ambulance teams to understand and predict for
ambulance arrivals to the ED so that resources can be matched
The Trust expects to be compliant with this standard for Q1 2015/16
67
Working with patients/partners to improve patient experience
How we respond to patient and public
feedback on their experiences of care
in hospital is critical to ensuring the
public can have trust and confidence
in us as well as in maintaining staff
morale. We learn from a wide range of
sources including complaints and
concerns, patient surveys and from
key groups, such as our governors,
our membership and more directly via
the Patient Partnership Group.
The national inpatient survey (July
2013) reported responses to 85
questions and provides us with a
snapshot of how we compare to
national averages. The full report
was published in February 2014
and can be viewed at
https://www.picker-results.org.
In addition to the national and
monthly Trust-wide surveys, we
support approximately 30 different
specialty level patient surveys, in
diverse topics such as End of Life,
Children’s Services and the
Discharge Lounge.
The Friends and Family Test,
introduced nationally in 2013,
provides the opportunity for
feedback from patients. A single
question asks the person to
indicate ‘their likelihood of
recommending the hospital to
friends and family in need of care’.
We introduced the question in a
staged approach to all areas last
year and for 2014/15 intend to
increase the uptake of responses
in each area from our year end
position of 29.12% in acute
inpatients, 14.91% in ED and
15.07% in Maternity.
Safeguarding vulnerable people and children
Safeguarding vulnerable people has
been a high priority throughout 2014/5
and will continue to be at all times.
Key achievements of the Trust include:
A written safeguarding training
strategy including safeguarding
adults, mental health,
safeguarding children, mental
capacity act, deprivation of
liberty safeguards and The
Prevent Strategy (Counter
Terrorism Government policy).
The Trust has achieved and in
some cases exceeded
compliance levels for staff
being trained in safeguarding
adult’s level 1 and in
safeguarding children level 1, 2
and 3.
The Trust has representatives
at the Local Safeguarding
Children Board and subgroups,
Safeguarding Adult Board and
subgroups and Learning
Disability Partnership Boards.
The safeguarding team has
documented audit programmes
for the year, which are reported
via the Quality Assurance and
Learning Committee.
A Child Sexual Exploitation
(CSE) group has been formed
to ensure a robust Trust
response to the National
papers on CSE. The Trust has
representation at local
operational and strategic CSE
groups and involvement in the
Berkshire wide workshops to
evaluate and improve the
effectiveness of these groups.
Adult safeguarding alerts are
now recorded on the Datix
incident reporting system.
68
Cross cover for the
safeguarding team has been
assured.
Mental capacity assessment
forms have been piloted and
rolled out Trust wide; they will
be audited in April 2015 and
there has been a significant
amount of mental capacity
assessment and deprivation of
liberty awareness training
provided to frontline staff.
A Lead Nurse for Transition to
adult services has been
established in partnership with
the Thames valley Strategic
Clinical Network. ‘Transition’ is
the process of planning,
preparing and moving from
children’s health care to adult
health. This nurse is reviewing
pathways for transition at
RBFT and developing a new
system of “Ready, Steady, Go”
in select specialties to ensure
transition is a controlled and
planned process. This work is
being led by the Trust, and the
lead nurse will support
colleagues across the network
in the same project.
A Trust wide report of self harm
and suicide and action plan
was produced. Ligature audits
Trust wide are being competed
as part of ward risk
assessment process.
The Berkshire Rapid
Response, following
unexpected child death,
protocol has been updated.
Working with pre- hospital
partners including Westcall and
SCAS we have reviewed the
Paediatric sepsis pathway in
Berkshire West and supported
education/training for primary
care.
NHS Trusts in England have been
asked to draw up action plans in
relation to the “The report of the
investigation into matters relating to
Savile at Leeds Teaching Hospitals
NHS Trust” report within the next three
months setting out how they will
ensure patients are protected from
potential sexual predators. A task and
finish group will be established in April
and chaired by Tricia Pease, Director
of Nursing Urgent Care, and include
representation across the Trust.
69
Dementia care and training
A quarter of patients in UK hospitals
have a form of dementia, and the
number is growing. Dementia will
affect all of us in our work or our
personal lives.
In February 2009, the National
Dementia Strategy was launched. It
set requirements to ensure that all
staff working in health and social care
who might care for people with
dementia should have the necessary
skills.
We are the only Trust in the Thames
Valley to have met Health Education
England’s target to train 75% of staff
on the issues faced by patients with
dementia by December 2014. 3,214
staff received training which equates
to 76% of our total staff. From April we
will provide additional training for staff
who work frequently with patients who
have dementia. This will include
training in the simulation centre and eLearning.
Figure 30: Health Education Thames Valley Number of Staff Trained in Dementia 201415
Ensuring patients receive adequate food and fluid
Ensuring our patients are adequately
nourished is a highly important part of
our caring intentions. We have a Trust
Nutrition Steering Group that provides
expert multidisciplinary leadership and
guidance to our wards and addresses
all elements of nutritional support. In
The Trust has been inspected or
undertaken specific audits relating to
2014-15, on average, 90% (compared
to 91% in 2013-14) of patients were
screened for signs of malnutrition
within 48 hours of admission, using the
nationally mandated Malnutrition
Universal Screening Tool (MUST).
nutrition in 2014-15 with the following
results:
70
Environmental Health Office
(EHO) Inspection 5 Star
assessed as of ‘Very good
standard’
PLACE (Patient-led
assessments of the care
environment) 82.4% (previous
6 years 92-96%)
CQC Picker report in 2013-14
Royal Berkshire Hospital was
in the top 20% in the country.
We are awaiting the 2014
results.
Cardiology
Our Cardiology Service was once
again recognised as providing the
fastest lifesaving treatment for heart
attack patients / blood clots in the
country.
For the third year running our Cardiac
Unit has been named the speediest
24/7 centre anywhere in England and
Wales for providing patients with
primary angioplasty treatment within
120 minutes of them calling the
emergency services. The 120 minute
target is regarded as the most
important - and most challenging - one
to meet. In the latest annual statistics
released by the Myocardial Ischaemia
National Audit Project (MINAP), the
cardiac team are shown to be even
more efficient in ensuring patients are
treated as speedily as possible.
Nationally the figures reveal that
58.9% of heart attack patients receive
their treatment within the 120 minute
timeline while at the Royal Berkshire
Hospital the figure is 94.2%. The next
best performing unit recorded 82.4%.
Pride of Reading Awards
Our Cardiology team has won the
Health Team/Worker of the Year in
this year’s Pride of Reading Awards.
individuals throughout the Trust have
been nominated by patients who
believe our staff deserve to be
recognised for going the extra mile.
This year, more Trust staff have been
nominated for a Pride of Reading
award than ever before. Teams and
71
Mandated performance indicators 2014/15
Amended regulations from the Department of Health require trusts to include a core
set of quality indicators in 2014/15 Quality Accounts. These mandated indicators are
set out below. Where available, data has been drawn from the Health and Social
Care Information Centre.
Summary Hospital-level Mortality Indicator
Indicator
Summary of
Hospital level
Mortality
Indicator(SHMI)
value and [OD
banding]
SHMI percentage
of admitted
patients whose
deaths were
included in the
SHMI and whose
treatment included
palliative care
2010/1
1
2011/1
2
1.0954
1.0627
(2)
(2)
2012/1
3
1.0543
(2)
2013/1
4
2014/15
Nation
al
Averag
e*
NHS
Best
*
NHS
Worst
*
1.0624
(2)
1.79
Quarter
1 214/15*
1.3 (as
at Jan
15)
1.7
(as
at
Jan
15)
1.1
(as at
Jan
15)
24.6
(as at
Jan
15)
24.2
(as
at
Jan
15)
26.9(
as at
Jan
15)
37.67%
23.0%
23.3%
21.2%
23.4%
Quarter
1
2014/15
*
Footnote: * The value and banding of the summary hospital-level mortality indicator
(“SHMI”) for the Trust for the latest reporting period covers October 2013 to
September 2014, at the time of writing this report there were no further data
available. The Banding is for over-dispersion (OD Banding) and the Trust rated 2 of
7, with 1 being the best and 7 being the worst banding.
The Summary Hospital-level Mortality
Indicator (SHMI) reports on mortality at
Trust level across the NHS in England.
The SHMI is the ratio between the
actual number of patients who die
following a treatment at the Trust and
the number that would be expected to
die on the basis of average England
figures, given the characteristics of the
patients treated there.
The SHMI covers all deaths reported
of patients who were admitted to nonspecialist, acute NHS trusts in England
and either die while in hospital or
within 30 days of discharge.
The SHMI values are published along
with bandings indicating whether a
trust’s SHMI value is as expected’
(band 2), ‘higher than expected’ (band
1) or ‘lower than expected’ (band 3).
All trusts are encouraged to explore
and understand the activity which
underlies their SHMI using their own
locally held information. The SHMI
requires careful interpretation and
should not be taken in isolation as a
headline figure of trust performance. It
72
is best treated as a ‘smoke alarm'
which warrants a follow-up. The SHMI
is an indication of whether individual
trusts are conforming to the national
baseline of hospital-related mortality.
Our overall SHMI for the past 4 years in the preceding table shows us to be in line
with the national average with an ‘as expected’ banding.
Patient reported outcome measures (PROMS)
Indicator
Patient reported
outcome measure
groin surgery –
adjusted average
health gain
Patient reported
outcome measure
varicose vein –
adjusted average
health gain
Patient reported
outcome measure
hip replacement –
adjusted average
health gain
Patient reported
outcome measure
knee replacement
– adjusted
average health
gain
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
0.07
0.063
0.06
0.111
0.11
4
-
-
-
2014
/15
0.074
(April to
Sept
2014) *
National
Average
NHS
Best
NHS
Worst
0.081
0.1
30
0.006
0.001
0.0
33
0.145
-
-
Data
not yet
availabl
e*
0.492
(April to
Sept
2014)*
0.442
0.3
89
0.514
0.316
(April to
Sept
2014)*
0.328
0.2
43
0.391
0.445
0.407
0.41
0.440
0.43
3
0.341
0.283
0.297
0.327
0.30
8
*Final year data not published until after the publication of this report
Royal Berkshire NHS Foundation
Trust considers that this data is as
described for the following reasons:
the data is collected for us by a
contracted external organisation then
provided to the national Health and
Social Care Information Centre
(HSCIC) which publishes them in their
Quality Accounts section and from
where we pull the information.
The Trust undertakes very limited
numbers of varicose vein surgery and
the low numbers mean that for a six
month period they cannot be reported
without the risk of patient identification.
There is therefore no adjusted average
health gain to report at this time for
varicose vein surgery.
Royal Berkshire NHS Foundation
Trust has taken the following actions
to improve its score, and so the quality
of its services, by reviewing the care of
individual patients as case studies at
general Surgical Clinical Governance
meetings for groin hernia surgery and
at monitoring the hip and knee
PROMS within the Orthopaedic
Clinical Governance and Orthopaedic
73
Business meetings for hip and knee
replacement surgery.
Percentage of patients aged 0-15 and 16 years or over readmitted
to the Trust within 28 days of being discharged
Indicator
Emergency
readmissions to
hospital of
patients aged 015 within 28
days of
discharge
Emergency
readmissions to
hospital of
patients aged 16
or over within 28
days of
discharge
2009/1
0
2010/1
1
2011/1
2
2012/1
3
2013/1
4
2014/1
5
Nation
al
Avera
ge
NHS
Best
NHS
Worst
8.93
%
9.62
%
8.93
%
7.9%
Trust
data
7.2%
Trust
data
5.11
%
Trust
data
-
-
-
9.83
%
9.45
%
10.22
%
6.8%
Trust
data
6.7%
Trust
data
4.29
%
Trust
data
-
-
-
Royal Berkshire NHS Foundation Trust considers that this data is as described for
the following reasons: The Trust has completed readmission activity reconciliations
with both the Clinical Commissioning Group (CCG) and the national SUS
Readmission data extracts and has found its data to be in line with these external
readmission sources
Royal Berkshire NHS Foundation Trust has taken the following actions to improve its
services, and so the quality of its services, by regularly reviewing the emergency
admissions that appear to be related to the previous admission and ensuring that the
care and treatment for these patients is reviewed by the relevant clinical team.
74
The percentage of staff employed by, or under contract to, the
Trust during the reporting period who would recommend the Trust
as a provider of care to their families or friends
Indicator
2009/
10
2010/
11
2011/
12
2012/1
3
2013/14
The
percentage of
staff employed
by, or under
contract to, the
trust during the
reporting
period who
would
recommend
the trust as a
provider of
care for their
family and
friends.
65%
69%
71%
73%
74%
2014/15
Natio
nal
Avera
ge
NH
S
Bes
t
NHS
Wor
st
72%
66%
93
%
36
%
The percentage of patients who would recommend the Trust to
their family or friends
The Trust's score from a single
question survey which asks patients
whether they would recommend the
NHS service they have received to
friends and family who need similar
treatment or care.
It is new non-statutory indicator for
providers of NHS funded acute
services for inpatients and patients
discharged from A&E from April 2013.
Figures in the following table are the combined score for inpatients and A&E. The
Response rate in 2014/15 was 29.6%
Indicator
The percentage of Patients
who would recommend the
trust to their family or
friends
2013/14
2014/15
National
Average
NHS Best
NHS
Worst
xx%
(restate)
92.06%
90.4%
-
-
The Royal Berkshire NHS Foundation
Trust considers these data are as
described for the following reasons:
the data is collected for us by a
75
contracted external organisation then
provided to the national Health and
Social Care Information Centre
(HSCIC) which publishes them in their
Quality Accounts section and from
where we pull the information.
Patients admitted to hospital who were risk assessed for venous
thromboembolism
Indicator
Percentage of
admitted patients
risk assessed for
venous
thromboembolism
2009/
10
2010/
11
2011/
12
2012/
13
65%
90.1
%
94.7
%
91.3
%
2013/
14
95.68
%
2014/
15
96.1
%
Natio
nal
Aver
age
NHS
Best
NHS
Wors
t
96.01
%*
100
%*
74%*
* Data published in February 2015
The Royal Berkshire NHS Foundation
Trust has taken the following actions
to improve its percentage, and so the
quality of its services, by fostering an
open reporting culture, involving key
clinical staff to train others in the
importance of risk assessment and
collecting risk assessment data
electronically.
Clostridium Difficile (C difficile)
Indicator
Rate of C difficile
per 100,000 bed
days for specimens
taken from patients
aged 2 years and
over (Trust
apportioned cases)
2009/
10
2010/
11
2011/
12
2012/
13
2013/
14
2014/
15
Natio
nal
Aver
age
NHS
Best
NHS
Wors
t
Data not published
47.1
57.5
51.2
The Royal Berkshire NHS Foundation
Trust has taken the following actions
to improve its rate, and so the quality
of its services, by implementing
actions focused on appropriate stool
13.5
18.1
Trust
data
sampling; improved microbial
prescribing; environmental cleaning;
hand hygiene; and prompt isolation of
affected patients.
76
Patient safety incidents
Reportable Patient Safety Incidents/100
admissions
10.0
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
Indicator
2009/
10
2010/
11
2011/
12
2012/
13
2013/
14
Rate of patient
safety
incidents
reported -
Percentage of
incidents
resulting in
severe harm or
death
Number of
patient safety
incidents
NHS
Best
NHS
Worst
-
-
-
-
-
-
*
5.2
per
100
admiss
ions
(%)
per
1000
bed
days
(%)
2014/
15
Natio
nal
Avera
ge
5.5
5.1
5.9
5.7
39.35*
-
-
-
-
-
0.5%
0.8%
0.8%
0.3%
0.3%
-
-
-
5196
4798
5398
5070
-
-
-
0.15%
4991
8510
77
Number of
incidents
resulting
severe harm or
death
26
41
36
17
13
-
-
-
13
*Footnote
Patient safety incident data were extracted from the Trust’s internal incident
management system (DATIX) sourced for the time period, not the National Reporting
Learning System as the NRLS publish data in arrears and therefore is not available
for the full reporting period.
* In 2014/15 the National Reporting and Learning System (NRLS) changed the way
of measuring the rate of patient safety incidents from” per 100 admissions” to “per
1000 bed days”. There is no national comparative patient safety incident data
available from the NRLS for 2014/15.
At the Royal Berkshire NHS
Foundation Trust there is a positive
culture for reporting incidents.
Between April 2014 and March 2015
10129 incidents were reported.
78
Performance against other national indicators in 2013/14
The following table shows performance against mandated quality indicators relevant
to Acute Trusts in the 2013/14 NHS Operating Framework.
***Data reported is month 12 data (March 2015) unless otherwise advised
Benchmark
2011/
12
2012/
13
2013/
14
Reduce the incidence of
MRSA
0
0
1
0
0
Venous thrombosis Risk
Assessment
95%
94.7
%
91.3
%
95.6
%
96.1%
National Patient Survey Overall rating
93%
-data
93%
96%
98%
Single sex accommodation breaches
0
1
1
0
0
2014/1
5
What this
means
Safety
Low
number is
better
Higher
percentage
is better
Patient Experience
Higher
percentage
is better
Low
number is
better
Waiting Times
Admitted in 18 weeks
percentage
Non admitted in 18 weeks
percentage
90%
95%
92.31
%
99.42
%
91.8
%
99.2
%
93.8
%
99.9
%
77.45
%
Reporting
holiday
July 2014
to Dec
2014
96.34
%
Reporting
holiday
July 2014
to Dec
2015
91.56
%
18 weeks Incomplete
pathways
92%
Diagnostics in 6 weeks %
99%
89%
93.6
%
94.4
%
99.5
%
99.4
%
96.1
%
Reporting
holiday
July 2014
to Dec
2015
91.3%
Higher
percentage
is better
Higher
percentage
is better
Higher
percentage
is better
Higher
percentage
79
Benchmark
2011/
12
2012/
13
2013/
14
2014/1
5
What this
means
is better
2 week wait for suspected
cancer
93%
94.7
%
93.0
%
31 day first treatment: all
cancers
96%
96.5
%
97.6
%
62 day standard: all cancers
85%
85.0
%
85.3
%
A&E attendance within 4
hours Types 1 & 2
95%
95.6
6%
95.09
%
92.1
%
93.6
%
98.1
%
90.70
%
Higher
percentage
is better
97.2%
Higher
percentage
is better
86.3%
86.2
%
94.44
%
Operations cancelled on the
day for non clinical reasons
0.8%
2.70
%
0.53
%
0.55
%
0.69%
Cancelled operations
rebooked in 28 days
5.0%
2.64
%
7.32
%
4.78
%
5.2%
Higher
percentage
is better
Higher
percentage
is better
Lower
percentage
is better
Lower
percentage
is better
80
Annex 1: Statements from commissioners, local
Healthwatch organisations and Overview and
Scrutiny Committees
Berkshire West CCG and Berkshire East CCG Joint Response
Executive Summary
Berkshire West Clinical Commissioning Group (CCG) Federation has reviewed the
Royal Berkshire NHS Foundation Trust Quality Account and is providing a joint
response on behalf of Newbury and District CCG, South Reading CCG, North and
West Reading CCG, Wokingham CCG, Slough CCG, Bracknell and Ascot CCG and
Windsor Ascot and Maidenhead CCG, The Quality Account 2014/15 provides
information across a wide range of quality measurers and gives a comprehensive
view of quality of care provided by the Trust. There is evidence that the Trust has
relied on both internal and external assurance mechanisms.
The CCGs are satisfied as to the accuracy of the data contained in the Account and
also that the Trusts 2014/15 Quality Account Priorities are those that were set out in
the Trusts Vision and Strategic Objectives and five year plan. The CCGs agree that
the 6 key priorities identified by the Trust are appropriate and in line with findings and
discussions we have had with them throughout the year.
History
The Royal Berkshire NHS Foundation Trust is one of the largest general Hospital
Foundation Trusts in the country. They provide acute medical and surgical services
to Reading, Wokingham and West Berkshire and specialist services to a wider
population across Berkshire and its borders. Underneath their “Vision” sits their
strategic objectives and their five year plan which details how they aim to achieve
their objectives. The Trust very much values the partnership working across the local
health economy, and with their patients and the public. Berkshire West CCGs are
pleased to continue working in partnership with them.
Quality Account 2014/15
Their Quality Account for 2014/15 clearly identified their successes to date and also
areas for further improvement. The CCG’s support the Trust’s openness and
transparency and is committed to working with the Trust to achieve further
improvements and successes in the areas identified within the Quality Account. This
will be carried out through a number of both proactive and reactive mechanisms and
collaborative and integral working.
Priority 1: Patient safety: To improve the safety of our Maternity Service
We are pleased that the Trust has reviewed and improved both its management
structures, consultant establishment and governance processes ensuring greater
accountability for service quality and robust assurance during 2014/15. We also
welcome the Trust gathering and reviewing feedback from both the staff and women
surveys to identify areas for improvement, which have assisted in the development of
the Trusts maternity improvement plan going forwards. We are pleased that the
Trust has chosen this as a priority area for 2015/16 and are encouraged by the
Trusts plans to further improve the safety of their maternity service.
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Priority 2: Patient Safety: Improve learning from patient safety incidents and
our systems for learning from them
The Trust has worked hard in 2014/15 to increase their incident reporting and have
made steady progress, which has resulted in the Trust no longer considered to be an
outlier. Incident reporting is essential in providing an opportunity to learn from past
events and to ensure that steps are taken to minimise recurrences. We welcome the
Trust continuing to prioritise further improvement in this area, particularly their plan to
improve sharing of learning to relevant parties and their aim to drive a culture which
encourages asking staff to speak up and speak out and ‘zero tolerance’ of never
events.
Priority 3: Clinical effectiveness: Improving the availability and quality of
medical records
We welcome the extensive work that was undertaken in 2014/15 to improve the
availability and quality of medical records. This included identifying ‘champions’ from
various staff groups to drive improvement, changes to the way in which records are
delivered to outpatient clinics and the development of Key Performance Indicators
(KPIs) to enable more robust monitoring of progress being made in this key area. We
welcomed the Trust undertaking a security of records audit and quality of content
audit to further inform required improvements going forward. We are again pleased
that the Trust has chosen this as a quality priority for 2015/16. Good quality medical
records are essential in supporting safe patient care and although a lot of progress
has been made; there is still work to be done in this key area.
Priority 4: Reducing waiting times to ensure treatments received at the right
time
During 2014/15 the Trust has worked extremely hard to improve waiting times. This
has included working with Planned Care and Informatics specialists to develop,
implement and embed processes and disciplines, providing greater assurance to the
Trust Board and us as commissioners. Although there has been a significant
improvement, the Trust has still failed to achieve the 62 day cancer target (GP
referrals) and the 18 week referral to treatment target. We therefore welcome the
Trust identifying reducing waiting times to ensure treatments received at the right
time as a priority area to build on the work already undertaken this year. We support
the plans outlined to make the Trusts system efficient whilst improving the quality of
care provided to patients and the aim to achieve the national targets for RTT, A&E
access and Cancer waiting times in 2015/16.
Priority 5: Patient experience: Improving safety and timely discharge of
patients
We recognise the value of improving ‘patient flow’ which can increase patient safety
by ensuring they receive the right care, at the right time, all of the time. The Trust has
worked hard on this area over 2014/15 and we welcome their plans to further
develop this as a priority for 2015/16. We are encouraged by the Trust’s vision to
promote boundary-less patient flow where the patient’s journey is thought about
beyond just the 4 walls of the hospital. We fully support the Trusts plans and look
forward to seeing the impact across 2015/16.
Priority 6: Patient experience: Improving administration systems to improve
booking processes, reducing cancellations and access to hospital
We are aware that concerns about clinical treatment, communication, administration,
personal care and building, environment and equipment form the top themes
regarding formal complaints for the Trust and that the Trust has good systems and
processes for sharing the learning across the organisation. We support that a focus
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on improving administration processes and better use of technology and roles will
improve the patient journey and patient experience, so welcome this priority. We are
particular pleased with the plan to provide a single point of access for patients and
GPs, which we feel will greatly improve patient care and experience.
Overall
Following the publication of the Trust’s CQC inspection on 24th June 2014, where the
Trust received an overall rating of requires improvement; we have seen the Trust
make significant progress in addressing the key areas of concern outlined in this
report. We are pleased that the Trust has chosen to focus priorities on improving the
safety of maternity services and improving the availability and quality of medical
records, because these were key findings in the CQC report and although a vast
amount of work has been undertaken over the past year, there is still work to be
done.
We acknowledge the work undertaken by the Trust to reduce the number of
operations cancelled on the day of surgery for non-clinical reasons and share the
Trusts disappointment at not achieving the improvement set out in last year’s quality
account, but accept that this was an ambitious target. We welcome the Trust
continuing with the work they have started in this area to further improve.
From the 2014/15 priorities patient safety: improve harm free care the Trust had a
number of areas for improvement. One key area was falls and the Falls Steering
Group has been overseeing the falls prevention and management work programme.
Though falls are not identified as a 2015/16 priority the improvement momentum
must be maintained so that progress can continue on a downward trajectory. This is
because falls with harm as identified as a serious incident are still being reported by
the Trust. The Trust has had a number of Never Events during 2014/15 which have
resulted in learning for the Trust. The data for the Hospital Standardised Mortality
Ratio (HMSR) was not available at the time of writing but from the available
information deaths at weekends are still higher than during the week the CCG’s will
continue to review the data to ensure further improvement.
We also acknowledge the hard work undertaken to improve performance in staff
compliance with safeguarding children and adult training and are really pleased that
the Trust has achieved full compliance with safeguarding children training levels 1, 2
and 3 and safeguarding adult training level 1 on 31st March 2015, meeting national
requirements.
We support the Trust in its continuing focus on the positive results from 2014/15
priorities and their continuing work to further those improvement and strengthen
priorities next year. Overall there have been many positive highlights for the Trust
and assurance that they continue to offer high quality and safe care to our patients.
The information in this Quality Account is provided from the Trust’s data
management systems and their quality improvement systems and to the best of our
knowledge is accurate, and provides a true reflection of the organisation.
Healthwatch West Berkshire Response
Thank you for the opportunity to comment on this year’s Quality Account. We have
some general comments then a few specific ones related to particular sections.
We are pleased to see improvements in a number of areas and achievements such
as the positive staff survey, the Trust being rated by the Health Service Journal as
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one of the best places to work, and continued top performance for speedy cardiac
treatment.
Inevitably because of timescales, comments have to be on non-final drafts and we
appreciate that there may be changes in the final version.
Quality Accounts are an important way in which Trusts can formally report to local
communities about quality and improvement. While we welcome the inclusion of a
glossary, we think more could be done in future, such as more consistent use of plain
English, to make the report more accessible.
Turning to the priorities for the coming year, we welcome these as areas requiring
improvement (and are glad that Maternity Services are included, as we suggested
last year).
We were pleased to see the continued intention to take action on medical records, as
this appears to be something which could have a wide-ranging impact on efficiency
and effectiveness. However it is hard, from the information presented, to get a clear
sense of a strategic way forward and particularly, as we mentioned last year, on how
or when the move to electronic records will be achieved.
In reviewing performance against last year’s aims it would be helpful if there could be
consistent reporting against all the aims set last year, which is not always the case
(e.g., on weekend survival rates, there is no mention on success against the aim that
90% of patients admitted to ED with suspicion of infection receive antibiotics within
one hour). In some cases there is no specific information on the targets. In others,
information is presented but the narrative does not indicate whether the target has
been achieved (e.g. there was a target last year under Priority 6, for ophthalmology
waiting times and while the outturn figures are given, (in Fig 24, p.56 of the draft),
whether the target was met is not specifically mentioned). Also it would be helpful to
have some commentary on why targets have not been achieved (it may be for very
good reasons) and what action is to be taken in future.
On the Friends and Families test (FFT) (under Courtesy, Communications and
Behaviours) the target was in terms of the net promoter score, which the text says
was met, but the figure given (98%) is calculated on a different basis and this is not
explained. It is not explained that the way the FFT is presented has been changed
nationally, or to show calculations under the old and new methodology (although
based on the figures given we calculate that the net promoter score for February
2015 would have been 78, which did meet the target).
It is not clear why figures for complaints were only available for the first two quarters,
up to the end of September rather than at least December (p.52 of the draft).
Hopefully for the final version there will be figures for the whole year together with
some commentary on whether the targets were met, if not why not and what remedial
action is necessary.
We were pleased to see that the staff survey has a number of responses in the top
20% of trusts and others that are better than average and that the trust is rated as
one of the best places to work by the HSJ.
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It is good to hear that the Francis Report action plan has been implemented, and the
range of issues being addressed and recognition of continuing underlying issues
where more progress is needed provides confidence in the seriousness with which
this is being taken.
The Trust is also to be to be congratulated on the Cardiac centre continuing to be the
speediest in England and Wales for primary angioplasty treatment within 120
minutes.
Healthwatch Reading Response
Thank you for the opportunity to comment on your Quality Accounts. We welcome
the priorities that have been set for this coming year, especially around patient safety
and patient experience: improving safety and timely discharge, which we have found
to be a particular concern for patients and their families, as was demonstrated in the
piece of work carried out by Healthwatch Reading last year supported by RBFT. It is
a little disappointing that there is no reference to the Healthwatch report and how
you have acted or committed to act on this to improve patient experience. There
were key recommendations within the report around improving the way RBFT staff
should improve the way they communicate discharge dates and times to people, as
well as just getting people out quicker. We would look to see these are met, as they
would improve the patient journey and experience. There is also little reference to
integrated working and how you are working with others to improve this pathway.
We welcome the complaints training that you have introduced for staff. In our
advocacy role we have learnt how important showing genuine sympathy and talking
to the patient openly as an equal is in the complaints process. Therefore
even though we welcome the training element that includes 'demonstrating sympathy
while maintaining control of the conversation' - we hope this would demonstrate
equality in the conversation and not what sounds like talking 'to' the patient, rather
than staff talking to patients as equals.
We are keen to see that RBFT continues to meet its priority on improving
communication by 'improving the quality of the response' to patient complaints.
However we would be keen to see the evidence behind this, as we know that many
clients we have dealt with have not been wholly satisfied with the response they have
received. Therefore we feel that communication should remain a key priority for
RBFT as this continues to be at the heart of most patient complaints.
We welcome your pledge to the 'Sign up to Safety' campaign. However we would be
keen to know how RBFT will go about changing staff atttitudes and behaviours.
What measures will you put in place? How will these be reported? In order to show
that staff and concerned members of the public feel they can report openly.
We also welcome the priority on Medical notes. In our recent Enter and View Visit to
Ophthalmology at RBFT, we heard from a number of patients who were being
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delayed due to the unavailability of medical notes and would look to see
improvements in this area.
Finally we note that there is some final data missing within the report which means
we cannot provide complete comment over all the information.
Thank you once again for the opportunity to comment and we hope to continue to
work with RBFT to ensure that patient feedback and experience of services are best
meeting local people's needs.
Healthwatch Bracknell Forest Response
Thank you for the opportunity to comment on your 2015 Quality Account.
We note that there is an increasing focus on patient safety including reviewing
serious incidents and learning from them to making maternity services safer.
Healthwatch Bracknell Forest whist not having any specific evidence from the public
in the previous year welcomes
"Healthwatch Bracknell Forest, whist not having any specific evidence from the public
in the previous year, welcomes these priorities for 2015/16."
We have received positive feedback about the services now offered from Brants
Bridge within Bracknell however we have highlighted the need for Macmillan
volunteers to be stationed there as patients have expressed that service as
“invaluable”.
We note that you are making effective discharge a priority and we have received
some feedback throughout the year from patients stating:- “discharge was at an
inappropriate time (10PM) with no regard for transport” and “discharge paperwork
bore no resemblance to my stay”. The priority to make records better and enhance
the discharge experience is very much welcomed.
Other feedback throughout the year was on the quality of food which was described
in several accounts as appalling and needing improvement. The cost to patients to
watch tv and have some communication was highlighted as being expensive and
patients have also stated they would like wi-fi throughout their stay to be free and
available to all.
Staff attitude in some areas has been criticised and we welcome the new initiatives to
address poor staffing standards.
Positive feedback was received on cancer and renal services at the main location as
well as at Brants Bridge.
We look forward to continuing to work with Royal Berkshire NHS Foundation Trust
with the aim to improve patient engagement and experience.
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Wokingham Borough Council Health Overview and Scrutiny
Committee response
'Members of the Wokingham Health Overview and Scrutiny Committee have
reviewed the Trust's Draft Quality Account Report and have noted the priorities for
2015/16. The inclusion of 'Improving the safety of our maternity services' as a priority
for next year is welcomed. Members were also pleased to note the success of the
Cardiology Team, the level of staff who would recommend the Trust to Friends and
Family and the number of readmissions within 28 days of discharge.
Whilst it is disappointing that the Trust is likely to fail to achieve the Cancer 62 day
target (GP referrals) and the Cancer two week wait targets (all cancers) it is
encouraging to see that reducing waiting times to ensure treatments received at the
right time is a priority for 2015/16.'
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Annex 2: Limited assurance by external auditors
***This statement is subject to change to reflect KPMG’s work on mandated
indicator testing carried out this year – final statement to be included when report is
submitted to the Trust’s Audit and Risk Committee on 18 May 2015***.
Independent Auditor’s Report to the Council of Governors of Royal Berkshire
NHS Foundation Trust on the Quality Report
We have been engaged by the Council of Governors of Royal Berkshire NHS
Foundation Trust to perform an independent assurance engagement in respect of
Royal Berkshire NHS Foundation Trust’s Quality Report for the year ended 31 March
2015 (the “Quality Report”) and certain performance indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March 201 subject to limited assurance consist
of the national priority indicators as mandated by Monitor:
percentage of incomplete pathways within 18 weeks for patients on incomplete
pathways at the end of the reporting period and
62 Day cancer waits – Percentage of patients receiving first definitive treatment
for cancer within 62 days of an urgent GP referral for suspected cancer; and
We refer to these national priority indicators collectively as the “indicators”.
Respective responsibilities of the directors and auditors
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;
the Quality Report is not consistent in all material respects with the sources specified in the Detailed Guidance for External Assurance on Quality Reports;
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 and papers for the period xxx April 2014 to xxx May 2015;
Papers relating to quality reported to the board over the period April 2013 to 27 May
2014;
Feedback from the commissioners dated xxx May 2015
Feedback from governors dated xxx May 2015;
Feedback from Healthwatch Bracknell Forest dated xxx May 2015;
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Feedback from Healthwatch West Berkshire dated xxx May 2015;
Feedback from Healthwatch Reading dated xxx May 2015;
Feedback from Wokingham Borough Council Health Overview and Scrutiny
Committee dated xxx May 2015;
Feedback from Bracknell Forest Council's Health Overview and Scrutiny dated
xxx May 2015;
The Trust’s complaints report published under regulation 18 of the Local
Authority Social Services and NHS Complaints Regulations 2009, dated xx May
2015;
The latest national patient survey February 2015;
The national staff survey February 2015;
The Head of Internal Audit’s 2014/15 annual opinion over the Trust’s control
environment; and
Care Quality Commission intelligent monitoring reports provided during the
2014/15 period.
We consider the implications for our report if we become aware of any apparent
misstatements or material inconsistencies with those documents (collectively, the
“documents”). Our responsibilities do not extend to any other information.
We are in compliance with the applicable independence and competency
requirements of the Institute of Chartered Accountants in England and Wales
(ICAEW) Code of Ethics. Our team comprised assurance practitioners and relevant
subject matter experts.
This report, including the conclusion, has been prepared solely for the Council of
Governors of Royal Berkshire NHS Foundation Trust as a body, to assist the Council
of Governors in reporting Royal Berkshire 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 Royal Berkshire NHS
Foundation Trust for our work or this report save where terms are expressly agreed
and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement 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.
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.
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Reading the documents.
A limited assurance engagement is smaller in scope than a reasonable assurance
engagement. The nature, timing and extent of procedures for gathering sufficient
appropriate evidence are deliberately limited relative to a reasonable assurance
engagement
Limitations
Non-financial performance information is subject to more inherent limitations than
financial information, given the characteristics of the subject matter and the methods
used for determining such information.
The absence of a significant body of established practice on which to draw allows for
the selection of different but acceptable measurement techniques which can result in
materially different measurements and can impact comparability. The precision of
different measurement techniques may also vary.
Furthermore, the nature and methods used to determine such information, as well as
the measurement criteria and the precision thereof, may change over time. It is
important to read the Quality 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 governance over quality or nonmandated indicators which have been determined locally by Royal Berkshire NHS
Foundation Trust.
Conclusion
Based on the results of our procedures, nothing has come to our attention that
causes us to believe that, for the year ended 31 March 2014:
the Quality 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 above; 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.
KPMG LLP, Statutory Auditor
15 Canada Square, London, E14 5GL
xx May 2015
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Annex 3: Statement of directors’ responsibilities
for the quality report
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;
the content of the Quality Report is not inconsistent with internal and external
sources of information including:
-
Board minutes and papers for the period 1 April 2014 to 26 May 2015
Papers relating to Quality reported to the board over the period 1 April
2014 to 26 May 2015
- Feedback from the commissioners dated 7 May 2015
- Feedback from governors dated 5 May 2015
- Feedback from Healthwatch Bracknell Forest dated 26 April 2015
- Feedback from Healthwatch West Berkshire dated 05 May 2015
- Feedback from Healthwatch Reading dated 25 April 2015
- Feedback from Wokingham Borough Council Health Overview and
Scrutiny Committee dated 24 April 2015
- The Trust’s complaints report published under regulation 18 of the
Local Authority Social Services and NHS Complaints Regulations
2009, dated 13/05/2014;
- The latest national patient survey February 2015
- The latest national staff survey February 2015
- The Head of Internal Audit’s annual opinion over the trust’s control
environment dated xx May 2015
- CQC intelligent monitoring reports dates July 2014 and December
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
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the Quality Report has been prepared in accordance with Monitor’s annual
reporting guidance (which incorporates the Quality Accounts regulations)
(published at www.monitor.gov.uk/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
………………………Date……………………………………….Chairman
………………………Date……………………………………….Chief Executive
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