James Paget University Hospitals
NHS Foundation Trust
Quality Account
2012/13
Patient Care
James Paget University Hospitals
NHS Foundation Trust
Patient Safety
Staff Experience
Where you come first
FOREWORD
What is a Quality Account?
All providers of NHS services in England have a statutory duty to produce an annual report to the
public about the quality of services they deliver. This is called the Quality Account. Quality Accounts
aim to increase public accountability and drive quality improvement within NHS organisations. They
do this by getting organisations to review their performance over the previous year, identify areas for
improvement, and publish that information, along with a commitment to you about how those
improvements will be made and monitored over the next year.
Quality consists of three areas which are key to the delivery of high quality services:
• Patient safety
• How well the care provided works (clinical effectiveness)
• How patients experience the care they receive (patient experience)
Some of the information in a Quality Account is mandatory but most is decided by patients and carers,
Foundation Trust Governors, staff, commissioners, regulators, and our partner organisations,
collectively known as our stakeholders.
Scope and structure of the Quality Account
This report summarises how well the James Paget University Hospitals NHS Foundation Trust did
against the quality priorities and goals we set ourselves for 2012/13. It also sets out those we have
agreed for 2013/14 and how we intend to achieve them.
This report is divided into four sections, the first of which includes a statement from the Chief
Executive and looks at our performance in 2012/13 against the priorities and goals we set for patient
safety, clinical effectiveness and patient experience.
The second section sets out the quality priorities and goals for 2013/14 for the same categories and
explains how we decided on them, how we intend to meet them, and how we will track our progress.
The third section sets out how we identify our own priorities for improvement and provides examples
of how we have improved services for patients. It also includes performance against national priorities
and our local indicators.
The fourth section includes statements of assurance relating to the quality of services and describes
how we review them, including information and data quality. It includes a description of audits we
have undertaken and our research work. We have also looked at how our staff contribute to quality.
The annexes at the end of the report include the comments of our external stakeholders including:
• Great Yarmouth and Waveney Clinical Commissioning Group
• Healthwatch Norfolk
• Healthwatch Suffolk
• Governors‟ Council
• Health Overview and Scrutiny Committee
The annexes also include a glossary of terms used.
Any text shown in blue boxes is a compulsory requirement to be included in the Quality
Account as mandated within Monitor‟s Annual Quality Reporting Manual.
If you or someone you know needs help understanding this report, or would like the information in
another format, such as large print, easy read, audio or Braille, or in another language, please contact
our Assistant Director of Governance, Safety and Compliance by calling 01493 452887 or emailing
anna.hills@jpaget.nhs.uk.
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
1
Part 1 Statement on Quality from the Chief Executive
The last year has been one of continuous clinical improvement, particularly around our
bedside care. This resulted in the CQC declaring the Trust fully compliant with their
standards in July 2012. The improvements continued, performance was sustained and the
Trust remains fully compliant following an inspection in February 2013. Everyone associated
with the James Paget University Hospitals should be proud of those achievements
A&E waiting time performance improved significantly throughout the year with the 95%
target being met consistently since April 2012. The hospital also made real progress on the
18-week waiting times target for elective care. In April 2012, 2,060 patients were waiting
more than 18 weeks after a very difficult winter period and this was reduced to 620 patients
by October 2012
The Trust has continued to work closely with partner organisations to develop new ways of
working across health and social care provision. This work forms a key part of meeting the
funding challenge in the public sector. Our staff have participated in this work, giving
important clinical input to the service changes. The commitment of staff has been truly
commendable during the year and I acknowledge the great contribution and achievement
they have made. We will continue to strive for exceptional high quality, safe and
compassionate care for all our patients and their families and to provide the right care, in the
right place at the right time.
The appointment of Christine Allen as Chief Executive is the next important chapter for the
Trust. Christine has a solid platform upon which to build for the future and I wish her and
everyone associated with our hospitals, every success.
To the best of my knowledge, the information in this document is correct.
Signature
David Hill
Chief Executive
James Paget University Hospitals NHS Foundation Trust
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
2
Organisational Structure for Quality Performance
BOARD OF DIRECTORS (monthly)
Meetings in Public
GOVERNORS COUNCIL
(5 times per year)
Chair: Chairman of Trust
Chair: Chairman of Trust/Governors
AUDIT COMMITTEE
Bi-Monthly
TRANSFORMATION BOARD
Fortnightly
SAFETY and QUALITY GOVERNANCE COMMITTEE
Bi-Monthly
Chair: Non-Executive Director
Chair: Chief Executive
Chair: Non-Executive Director
HEALTH & SAFETY &
STAFF WELFARE
COMMITTEE
Bi-Monthly
PATIENT SAFETY
COMMITTEE
Bi-Monthly
CLINICAL AUDIT &
EFFECTIVENESS
COMMITTEE
Bi-Monthly
PATIENT & CARER
EXPERIENCE
COMMITTEE
Bi-Monthly Meetings
INFORMATION
GOVERNANCE
ACTION GROUP
Monthly
ADVERSE EVENT
REVIEW GROUP
Bi-Monthly
Chair: Director of
Workforce &
Organisational
Development
Chair: Director of
Nursing
Chair: Medical Director
Chair: Director of
Nursing
Chair: Caldicott
Guardian or Senior
Information Risk Officer
Chair: Assistant Director
of Governance, Safety
and Compliance
Quality as a core part of Board meetings
Over the past twelve months the Trust has significantly enhanced its structure in order to
support a greater focus on quality. The Trust commissioned an external review of its
governance systems and processes early in 2012 which has resulted in a number of positive
changes including a greater focus in terms of breadth and depth of discussion at the Board
of Directors monthly meetings on the quality agenda. The detailed Quality and Performance
Dashboard is presented to the public meeting of the Board of Directors each month which
includes details of serious incidents and never events, complaints, infection control matters,
Commissioning for Quality and Innovation (CQUIN) and other quality indicators.
Furthermore, the Trust assessed itself against Monitor‟s Quality Governance Framework
early in 2012. This identified a number of improvement actions which have been completed
and a re-assessment in October 2012 demonstrated a significant improvement against this
framework which was validated by the Trust‟s external auditors.
Part of the work undertaken was a review of the committee structure responsible for
assessing quality and safety and hence providing assurance to the Board of Directors. The
Safety and Quality Governance Committee is a sub-committee of the Board which meets bimonthly. The work programme of this Committee has been strengthened and is now more
aligned to the work of the Trust‟s Audit Committee. The Trust now has a Patient Safety
Committee, a Health, Safety and Staff Welfare Committee and a Clinical Effectiveness
Committee which feed directly into the Safety and Quality Governance Committee regarding
the Trust‟s performance in relation to these three domains of quality. Quality issues are
discussed in detail including adverse incidents and items on the risk register as well as
specific key performance indicators, at each of these meetings. These meetings are chaired
by Executive Directors with Non-Executive members and patient representatives on each
group.
Contents
FOREWORD ........................................................................................................................ 1
What is a Quality Account? ............................................................................................... 1
Scope and structure of the Quality Account....................................................................... 1
Part 1 Statement on Quality from the Chief Executive ........................................................... 2
Organisational Structure for Quality Performance ............................................................. 1
Quality as a core part of Board meetings ....................................................................... 1
Part 2 Priorities identified in the 2011/12 Quality Account ..................................................... 3
Priorities for Quality Improvement 2013/14 ........................................................................... 4
1
Patient Safety ............................................................................................................. 5
2
Clinical Effectiveness.................................................................................................. 7
3
Patient and Staff Experience ...................................................................................... 9
Statements of Assurance from the Board: ....................................................................... 11
Clinical Audits and National Confidential Enquiries ......................................................... 12
National Confidential Enquiries.................................................................................... 18
Participation in Clinical Research .................................................................................... 19
The Commissioning for Quality and Innovation (CQUIN) Framework .............................. 19
The Care Quality Commission (CQC) ............................................................................. 20
Quality of Data ................................................................................................................ 20
Hospital Episode Statistics .......................................................................................... 20
Information Governance .............................................................................................. 20
Payment by Results .................................................................................................... 21
Part 3 Review of Quality 2012/13 ........................................................................................ 23
1
Patient Safety ........................................................................................................... 23
(a)
To achieve and maintain compliance with all Care Quality Commission (CQC)
outcomes .................................................................................................................... 23
2
3
Clinical Outcomes and Effectiveness: ....................................................................... 24
(a)
Achievement of the CQUIN scheme .................................................................. 24
(b)
Reduce hospital acquired pressure ulcers across the Trust ............................... 24
Care and Staff Experience:....................................................................................... 29
(a)
To embed the recommendations from the Organisational Development Review
related to patient experience ....................................................................................... 29
(b)
Achieve year one objectives toward ensuring compliance with NHS Equality
Delivery System .......................................................................................................... 32
4
A Listening Organisation .......................................................................................... 33
Complaints .................................................................................................................. 33
Compliments ............................................................................................................... 36
Patient Advice and Liaison Service (PALS) ................................................................. 38
Patient experience measurement tools ........................................................................... 39
Emergency Department Survey................................................................................... 41
The Survey of Adult Inpatients..................................................................................... 41
5
External review ......................................................................................................... 44
Care Quality Commission (CQC) ................................................................................. 44
PLACE – Patient Led Assessments of the Care Environment ..................................... 44
Environmental Health .................................................................................................. 45
Monthly Cleanliness Reports ....................................................................................... 45
6
Other Indicators ........................................................................................................ 46
Summary hospital-level mortality indicator (SHMI) ...................................................... 46
Patient Reported Outcome Measures (PROMs) .......................................................... 47
Hospital re-admissions ................................................................................................ 48
Venous Thromboembolism (VTE) risk assessments ................................................... 49
Clostridium difficile (C.difficile) ..................................................................................... 51
Patient Safety Incidents ............................................................................................... 52
Responsiveness to the personal needs of patients (CQUIN) ....................................... 54
Percentage of staff who would recommend the Trust to their family and friends .......... 55
Staff Survey Report ..................................................................................................... 56
Monitor's Governance Indicators…………………………………………………………….59
Annex 1 – Statements from stakeholders ............................................................................ 60
Great Yarmouth and Waveney Clinical Commissioning Group ........................................ 60
Healthwatch Norfolk ........................................................................................................ 60
Healthwatch Suffolk ...................................................................................................... 611
Governors Council ........................................................................................................ 611
Health Overview and Scrutiny Committee ..................................................................... 633
Annex 2 – Statement of directors‟ responsibilities in respect of the Quality Report ............ 644
Glossary of terms and abbreviations ................................................................................. 655
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
2
Part 2 Priorities identified in the 2011/12 Quality Account
Below is a summary of how we did against our targets we set for ourselves going into
2012/13. Full details can be found in Part 3, Review of Quality 2012/13.
1. Patient Safety:
(a) To achieve and maintain compliance with all Care Quality Commission (CQC)
outcomes
Achieved
2. Clinical Outcomes and Effectiveness:
(a) Achievement of the CQUIN scheme
Achieved
(b) Reduce hospital acquired pressure ulcers across the Trust
Partially Achieved
3. Care and Staff Experience:
(a) To embed the recommendations from the Organisational Development Review
related to patient experience
Partially Achieved
(b) Achieve year one objectives toward ensuring compliance with NHS Equality Delivery
System
Achieved
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
3
Priorities for Quality Improvement 2013/14
The Board of Directors has agreed the following key priorities under the three domains of
quality for 2013/14. These have been identified following review of last year‟s priorities,
issues identified from the CQC assurance processes, complaints and incidents and priorities
identified by the NHS Commissioning Board.
The public and patients are involved in identifying risk and bringing this to the attention of the
Foundation Trust in a variety of ways:
Local Involvement Networks (now Healthwatch);
The Governors have been involved in setting the priorities within the Quality Accounts;
Involvement of patient representatives in the assessment of compliance with CQC
outcomes at ward level;
The Trust Board of Directors has continued to include a patient story at each monthly
meeting to help identify, manage and mitigate key risks;
Patients and relatives are involved in addressing issues identified through complaints,
claims, Patient Advice and Liaison (PALS) and incidents via involvement in action
planning;
Patient and/or Governor representatives are members of key Trust governance
committees;
Patient Satisfaction Surveys; and
Comprehensive survey and feedback involving staff, patients and their representatives,
led by April Consultancy LLP.
Public Stakeholders are involved in managing risk which impacts on them, for example:
There are Foundation Trust meetings at all levels with members of the Primary Care
Trust and Clinical Commissioning Group at which risk is assessed;
Health Overview and Scrutiny Committees;
Partnership working with Social Services; and
Joint working with other Trusts i.e. Norfolk & Norwich University Hospitals NHS
Foundation Trust, East of England Ambulance Service NHS Trust, Norfolk and Suffolk
NHS Foundation Trust, NHS Norfolk & Waveney and East Coast Community Health
Community Interest Company.
Definitions
Baseline
Goal
Monitoring and
reporting
Responsible Officer
Strategic Objective
A measured starting point
What the Trust aspires to achieve in a prescribed timescale
A clear process for measuring progress and reporting
Person within the Trust with overall responsibility for ensuring the
achievement of the goal
A broadly defined objective that an organisation must achieve to make
its strategy succeed.
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
4
1
Patient Safety
Priority
Rationale for selection
Baseline
Goal
Robust controls in
place which are
operating effectively
resulting in zero
Never Events during
2013/14.
(a) Never Events – to
embed systems,
processes and other
controls into practice
across all areas of the
Trust to reduce the risk
of Never Events
occurring.
Never Event
occurrences
experienced by the
Trust during 2012/13
and previous years,
hence controls require
strengthening.
Number of Never
Events reported
in 2012/13 (7)
(b) To reduce patient harm
and aim to deliver „Harm
Free Care‟ as defined by
the Safety Thermometer
(the absence of
avoidable pressure
ulcers, falls, urinary tract
infection in patients with
catheters and VTE) in
line with CQUIN/contract
requirements.
(c) To improve
documentation and
record keeping
compliance thereby
ensuring robust patient
assessments and plans
of care.
The four categories of
harm identified are still
being experienced by
patients at the Trust.
As defined by
the CQUIN/
contract.
Inadequate
documentation
continues to be a theme
from CQC assurance
audits.
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
Documentation
audits conducted
in March 2013.
As defined by the
CQUIN/contract.
Greater than 90%
compliance with
documentation
audits across all
areas of the Trust.
5
Monitoring and
reporting
Reporting via
Safeguard incident
reporting system.
Monitoring via
Governance
Committees and
Quality and
Performance
reports to Board
monthly.
Reporting via
Safeguard incident
reporting system.
Monitoring via
Governance
Committees and
Quality and
Performance
reports to Board
monthly.
Reporting via
Compliance Team
to CQC Monitoring
Group.
Responsible
Officer
Director of
Nursing
Strategic
Objective
1, 2
Director of
Nursing
1
Director of
Nursing
1, 2
Never Event - What is it?
Never Events are serious, largely preventable patient safety incidents that should not
occur if the available preventative measures have been implemented.
The core list of Never Events for 2012/13 is detailed below:
1. Wrong site surgery
2. Wrong implant/prosthesis
3. Retained foreign object post-operation
4. Wrongly prepared high-risk injectable medication
5. Maladministration of potassium-containing solutions
6. Wrong route administration of chemotherapy
7. Wrong route administration of oral/enteral treatment
8. Intravenous administration of epidural medication
9. Maladministration of Insulin
10. Overdose of midazolam during conscious sedation
11. Opioid overdose of an opioid-naïve patient
12. Inappropriate administration of daily oral methotrexate
13. Suicide using non-collapsible rails
14. Escape of a transferred prisoner
15. Falls from unrestricted windows
16. Entrapment in bedrails
17. Transfusion of ABO-incompatible blood components
18. Transplantation of ABO or HLA-incompatible Organs
19. Misplaced naso- or oro-gastric tubes
20. Wrong gas administered
21. Failure to monitor and respond to oxygen saturation
22. Air embolism
23. Misidentification of patients
24. Severe scalding of patients
25. Maternal death due to post-partum haemorrhage after elective Caesarean
section
Safety Thermometer - What is it?
Measures patients that are „harm free‟ at the point of care in a systematic way
Asks questions about four key outcomes:
Pressure ulcers
Falls
Urinary infection in patients with a catheter
Venous thromboembolism (VTE)
Integrates measurement into daily routines
Supports improvements in patient care and patient experience
Prompts immediate actions by healthcare staff
Allows us to measure in any setting where care is being delivered
„Harm free‟ care as defined by the absence of pressure ulcers, harm from a fall, urine
infection (in patients with a catheter) and new VTE.
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
6
2
Clinical Effectiveness
Priority
Rationale for
selection
Identified as a theme
from the Quality and
Performance
Dashboard.
Baseline
Goal
Baseline does not
apply to discrete
targets
Consistent compliance
with stroke metrics.
Specific local health
need as defined as a
priority in the
commissioning
intentions 2013/14.
As defined by the
CQUIN/contract.
As defined by the
CQUIN/contract.
(c) To increase participation in all
relevant national clinical audits
Identified via review of
clinical audit function
during 2012.
Percentage
compliance as at
31/03/2013 (65%)
(d) To increase rates of compliance
with all relevant NICE guidance
Focus within Francis
report and identified
following review of
clinical audit function
during 2012.
Percentage
compliance as at
31/03/2013 (77%)
Increase compliance to
80% of all relevant
national audits by
31/03/2014 with a clear
rationale as to why a
decision not to participate
has been made for the
remainder.
Increase compliance to
85% by 31/03/2014 with
a clear gap analysis for
all NICE guidance for
which the Trust is noncompliant.
(a) To improve and consistently
maintain compliance with the
metrics associated with high
quality stroke services - to ensure
patients, who are diagnosed with
a stroke, receive timely treatment
in an appropriate care setting and
that the Trust improves clinical
outcomes for patients with a
stroke.
(b) To improve services to better
meet the needs of patients living
with dementia
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
7
Monitoring and
reporting
Reporting via
Performance Team to
External Assessment and
Performance Group and
via Quality and
Performance Dashboard
to Management Team
and Board of Directors.
Responsible
Officer
Director of
Nursing
Strategic
Objective
1, 2, 5
Reporting via
Performance Team to
External Assessment and
Performance Group and
via Quality and
Performance Dashboard
to Management Team
and Board of Directors.
Reporting and monitoring
to Clinical Audit and
Effectiveness Committee.
Director of
Nursing
1, 2, 5
Medical
Director
2
Reporting via NICE
Implementation Group for
monitoring by Clinical
Audit and Effectiveness
Committee.
Medical
Director
2
NICE Guidance - What is it?
National Institute for Health and Care Excellence (NICE) guidance supports healthcare
professionals and others to make sure that the care they provide is of the best possible
quality and offers the best value for money.
They provide independent, authoritative and evidence-based guidance on the most effective
ways to prevent, diagnose and treat disease and ill health, reducing inequalities and variation
Their guidance is for the NHS, local authorities, charities, and anyone with a responsibility for
commissioning or providing healthcare, public health or social care services. They also
support these groups in putting their guidance into practice.
Francis Report - What is it?
On 9 June 2010 the Secretary of State for Health, Andrew Lansley MP, announced a full
public inquiry to examine the commissioning, supervisory and regulatory organisations in
relation to their monitoring role at Mid Staffordshire NHS Foundation Trust between January
2005 and March 2009. The Inquiry looked at why the serious problems at the Trust were not
identified and acted on sooner, to identify important lessons to be learnt for the future of
patient care.
The JPUH is currently reviewing the detail of the Francis Report and the 290
recommendations. The Department of Health is expecting all organisations to respond on
progress before the end of 2013 and then publish a yearly report. The CQC monitoring
group will be taking this work forward
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
8
3
Patient and Staff Experience
(c) To achieve
improvements in the staff
survey for specific areas
of concern
Rationale for
selection
A high percentage
of formal complaints
received indicate
dissatisfaction in
relation to staff
attitude and
communication.
Whilst mandatory
training uptake has
improved
significantly overall
some specific
subjects still
demonstrate low
levels of
compliance.
To improve
organisational
culture, staff health
and well-being
(d) To complete staffing
reviews and to approve
future steps/
recommendations.
Focus within Francis
report and on-going
internal workforce
analysis.
1. Priority
(a) Themes from complaints
– to reduce complaints,
concerns and patient
feedback related to staff
attitude and
communication.
(b) Mandatory Training –
ensure staff receive
mandatory training as
required
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
Baseline
Goal
Proportion of
complaint
issues related
to staff attitude
and
communication
during 2012/13
Quarter 3
2012/13
uptake rates.
Reduce proportion
by 5% for 2013/14
2012 staff
survey results
To improve scores
against all indicators
where the Trust falls
in the bottom 20% of
trusts nationally.
To complete phase 1
of the staffing
review, initiate phase
2 with regard to the
outcome of the Safer
Nursing Care Tool
into future workforce
plans.
Data from
assessment
via Hurst
model.
To achieve agreed
target percentage
levels for each
aspect of mandatory
training.
9
Monitoring and
reporting
Reporting and
monitoring to
Patient and Carer
Experience
Committee.
Responsible
Officer
Director of
Nursing
Strategic
Objective
2
Reporting monthly
to Divisions and
monitoring via
Mandatory
Training
Monitoring Group
and Quality and
Performance
Dashboard.
Monitoring via
Health, Safety and
Staff Welfare
Committee
Director of
Workforce
4
Director of
Workforce
4
Monitoring via
Workforce Review
Group.
Director of
Nursing
6
Hurst Model - What is it?
Simoens and Hurst (2006) provided a schematic model to assist with aligning workforce supply
with demand. The model was designed for the planning of physician services, but can equally
be applied to those of other health care professionals.
Safer Nursing Care Tool - What is it?
Developed by senior nurses, the Safer Nursing Care Tool provides a simple way of assessing
the safe number of nurses needed for a ward.
Nursing teams can use the Safer Nursing Care Tool to work out safe staffing on hospital wards
by putting in information about patients‟ conditions. They can also match staffing levels with
nursing performance in areas such as pressure sores, nutrition and falls, and compare results
with similar wards and departments at their hospital or other hospitals.
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
10
Statements of Assurance from the Board:
During 2012/13 the James Paget University Hospitals NHS Foundation Trust provided
the NHS services listed in the table below.
The James Paget University Hospitals NHS Foundation Trust has reviewed all the data
available to them on the quality of care in all of these services
The income generated by the NHS services reviewed in 2012/13 represents 100% of the
total income generated from the provision of NHS services by the James Paget
University Hospitals NHS Foundation Trust for 2012/13
Division
Emergency
Elective
Family and
Diagnostic Services
Specialties and services:
Accident and Emergency (A&E)
Care of the Elderly
General Medicine
Diabetic Liaison
Gastroenterology
Clinical Measurement
Endocrinology
Coronary Care
Diabetes
Endoscopy
Haematology
Rehabilitation
Cardiology
Intensive Care Services
Dermatology
Hyperbaric services
Nephrology and renal dialysis
Oncology
Genitourinary Medicine
Respiratory Medicine
Rheumatology
Therapies e.g. physiotherapy
Sandra Chapman Centre
General Surgery
Anaesthetics
Vascular Surgery
Audiology
Breast Surgery
Dental and Orthodontics
Gastro-intestinal Surgery
Community Dental Services
Urology
Oral Surgery
Trauma and Orthopaedics
Pain Management
Ear, Nose and Throat
Palliative Care
Clinical Specialties of Continence
Ophthalmology
and Stoma Care
Gynaecology
Paediatrics
Obstetrics
Paediatric Surgery
Maternity services
Children‟s Centre
Community midwifery
Community Paediatric Service
Neonatology
School Nursing (Great Yarmouth)
Parentcraft
Safeguarding children
Antenatal screening
Fertility services
Diagnostic Imaging:
Community services
Chemical Pathology
• X-ray services
Immunology and Serology
• Specialist Imaging
Microbiology
• Ultrasound services
Haematology
• Mammography services
Blood Transfusion
• MRI & CT services
Medical illustration
Bereavement Services
Pharmaceutical services
Pharmaceutical Services
Lowestoft Hospital
Social Work Support
Care of the elderly
GP beds
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
11
Clinical Audits and National Confidential Enquiries
During 2012/13 40 national clinical audits and 3 confidential enquiries covered NHS
services that the James Paget University Hospitals NHS Foundation Trust provides.
During 2012/13 the James Paget University Hospitals NHS Foundation Trust participated
in 65% (26 out of 40) national clinical audits and 100% national confidential enquiries of
the national clinical audits and national confidential enquiries which it was eligible to
participate in. In addition to this, the Trust participated in 16 national or regional clinical
audits not identified on the HQIP list for inclusion in Quality Accounts.
The national clinical audits and national confidential enquiries that the James Paget
University Hospitals NHS Foundation Trust was eligible to participate in during 2012/13
are [shown in the table below]:
The national clinical audits and national confidential enquiries that the James Paget
University Hospitals NHS Foundation Trust participated in during 2012/13 are [shown in
the tables below]:
The national clinical audits and national confidential enquiries that the James Paget
University Hospitals NHS Foundation Trust participated in, and for which data collection
was completed during 2012/13, are [shown in the table below] alongside the number of
cases submitted to each audit or enquiry as a percentage of the number of registered
cases required by the terms of that audit or enquiry [where available]
Audit Title
Relevant to
JPUH Services?
Trust
participation
Adult community acquired pneumonia (British Thoracic
Society)
Yes
Yes
Adult critical care (Case Mix Programme – ICNARC
CMP)
Yes
No
Emergency use of oxygen (British Thoracic Society)
Yes
Yes
Medical and Surgical programme: National Confidential
Enquiry into Patient Outcome and Death (NCEPOD)
(also known as Medical and Surgical Clinical Outcome
Review Programme, or Patient Outcome and Death)
Yes
Yes
National Joint Registry (NJR)
Yes
Yes
Non-invasive ventilation - adults (British Thoracic
Society)
Yes
Yes
Renal colic (College of Emergency Medicine)
Yes
Yes
Yes
Yes
Severe trauma (Trauma Audit & Research Network,
TARN)
Intra-thoracic transplantation (NHSBT UK Transplant
Registry)
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
Percentage of
Cases Submitted
Unknown at time
of writing.
JPUH was not
selected to
participate in
2012/13
Unknown at time
of writing.
See section below
Data collection
on-going
Unknown at time
of writing.
100%
Data collection
on-going
No
12
Relevant to
JPUH Services?
Trust
participation
Percentage of
Cases Submitted
National Comparative Audit of Blood Transfusion programme includes the following audits, which were
previously listed separately in QA:
a) O negative blood use (2010/11)
b) Medical use of blood (2011/12)
c) Bedside transfusion (2011/12)
d) Platelet use (2010/11)
Yes
Yes
100%
Potential donor audit (NHS Blood & Transplant)
Yes
Yes
100%
Bowel cancer (NBOCAP)
Yes
Yes
100%
Head and neck oncology (DAHNO)
Yes
Yes
Lung cancer (NLCA)
Yes
Yes
Oesophago-gastric cancer (NAOGC)
Yes
Yes
Acute coronary syndrome or Acute myocardial
infarction (MINAP)
Yes
Yes
Adult cardiac surgery audit (ACS)
No
Cardiac arrhythmia
Yes
Congenital heart disease (Paediatric cardiac surgery)
(CHD)
No
Coronary angioplasty
No
Heart failure (HF)
Yes
Yes
National Cardiac Arrest Audit (NCAA)
Yes
Yes
National Vascular Registry (elements include CIA,
peripheral vascular surgery, VSGBI Vascular Surgery
Database, NVD)
No
Pulmonary hypertension (Pulmonary Hypertension
Audit)
Yes
No
Adult asthma (British Thoracic Society)
Yes
Yes
Bronchiectasis (British Thoracic Society)
Yes
Yes
Diabetes (Adult) ND(A), includes National Diabetes
Inpatient Audit (NADIA)
Yes
Yes
Diabetes (Paediatric) (NPDA)
Yes
Yes
Inflammatory bowel disease (IBD)
Includes: Paediatric Inflammatory Bowel Disease
Services (previously listed separately on 2010/11
quality accounts list)
Yes
Yes
Audit Title
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
No
Data collection
on-going
Data collection
on-going deadline for
submission is
June. Assured
that 100% of
cases will be
submitted.
Data collection
on-going
Data collection
on-going
N/A
Data collection
on-going
Data collection
on-going
2013/14 data
collection still
TBC from HQIP
Unknown at time
of writing.
Unknown at time
of writing.
No participation in
ND(A).
NADIA not
available at time
of writing.
Data collection
on-going
Data collection
on-going
(deadline
30/06/2014)
13
Relevant to
JPUH Services?
Trust
participation
Percentage of
Cases Submitted
National Review of Asthma Deaths (NRAD)
Yes
Yes
100%
Pain database
Yes
No
N/A
Audit Title
Data collection
on-going - all
Renal replacement therapy (Renal Registry)
Yes
Renal transplantation (NHSBT UK Transplant Registry)
No
Mental Health programme: National Confidential Inquiry
into Suicide and Homicide for people with Mental
Illness (NCISH) (also known as Suicide and homicide in
No
Yes
cases submitted on
behalf of the JPUH
by NNUH.
N/A
mental health, or Mental Health Clinical Outcome Review
Programme)
National audit of psychological therapies (NAPT)
No
Prescribing Observatory for Mental Health (POMH)
(Prescribing in mental health services)
No
Carotid interventions audit (CIA))
No
Fractured neck of femur
Yes
No
Hip fracture database (NHFD)
Yes
Yes
National audit of dementia (NAD)
Yes
No
Parkinson's disease (National Parkinson's Audit)
Yes
Yes
Sentinel Stroke National Audit Programme (SSNAP) programme combines the following audits, which were
previously listed separately in QA:
a) Sentinel stroke audit (2010/11, 2012/13)
b) Stroke improvement national audit project (2011/12,
2012/13)
Yes
Yes
Elective surgery (National PROMs Programme)
Yes
Yes
Child health programme (CHR-UK) (Also known as the
Child Health Clinical Outcome Review Programme)
Yes
Yes
Epilepsy 12 audit (Childhood Epilepsy)
Yes
Yes
Maternal, infant and newborn programme (MBRRACEUK)*. (Also known as Maternal, Newborn and Infant
Clinical Outcome Review Programme)
Yes
Yes
No cases were
reported for
2012/13.
Neonatal intensive and special care (NNAP)
Yes
Yes
Data collection
on-going
Paediatric asthma (British Thoracic Society)
Yes
Yes
15 cases 100%
Paediatric fever (College of Emergency Medicine)
Yes
Yes
50 cases 100%
Paediatric intensive care (PICANet)
No
Paediatric pneumonia (British Thoracic Society)
Yes
Yes
Not available at
the time of writing
*This programme was previously also listed as Perinatal
Mortality (in 2010/11, 2011/12 quality accounts)
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
Data collection
on-going
2013/14 data
collection still
TBC from HQIP
Not available at
the time of writing.
Data collection
on-going
Data collection
on-going
Data collection
on-going
Not available at
the time of writing
14
The reports of 42 national clinical audits were reviewed by the provider in 2012/13 and
the James Paget University Hospitals NHS Foundation Trust intends to take the following
actions to improve the quality of healthcare provided:
Asthma management programme:
Medication
Appointment keeping
Prevention
o improving the patient-physician partnership to improve adherence
Prescribing antibiotics in the under-5s:
To review the practice of the Emergency Department and consider changes
World Health Organisation (WHO) safety checklist:
Raise awareness of for any radiological intervention to all staff directly involved in
these types of procedures
Encourage the use of Radiology checklists
The reports of 91 local clinical audits were reviewed by the provider in 2012/13 and
James Paget University Hospitals NHS Foundation Trust intends to take the following
actions to improve the quality of healthcare provided:
Paediatric Early Warning Scores (PEWS) – 3 actions including:
Teaching to be integrated into all new staff induction programmes
To improve recording, the PEWS section to be more of a focus of the observation
chart.
Clinical Negligence Scheme for Trusts (CNST) – 17 actions including:
Clearer documentation of antenatal admissions and associated VTE risk
assessments
Caesarean section debrief to become a component of a woman‟s discharge
pathway following caesarean section
Training exercises and seminars reviewing process required from decision to
delivery to be implemented.
Nutrition and hydration – 10 actions including
If weight is not documented on MUST chart, there should be a reason documented
All patients to have MUST assessment
teaching at trainee tutorials for new guideline for Nasogastric tube (NGT) placement
and maintenance
NGT check sheets in the bedside observations charts.
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
15
Theatres – 12 actions including:
Starvation time to be added to all booking slips for emergency theatre
Preparation of equipment and drugs for the evening before morning theatre list
Theatre Co-ordinator always on site and available in theatre
Extra staff for theatre turnarounds
Neutropenic sepsis – 6 actions including
Multinational Association of Supportive Care in Cancer (MASCC) score is important
and should be assessed and documented in all patients with neutropaenic sepsis
All patients assessed as low risk MASCC score for neutropenic sepsis to be
discussed with microbiologists.
Develop multi-disciplinary admission tool for febrile neutropenia patients in order to
confirm which samples required on admission and dates samples sent for analysis
Palliative Care – 6 actions including:
Change current proforma to include Palliative Care key worker and contact details
A copy of the Palliative Care Multidisciplinary Team (MDT) proforma will be faxed to
the GP and sent to medical records to be filed in patients case notes
Case Study 1
Audit on Adequacy of Consent for Transurethral Resection of the Prostate (TURP) 2011-2012
Objectives:
To assess if all patients are: 1) consented for bleeding, infection, dry ejaculation, impotence and
incontinence; 2) given written information on TURP; 3) consented at least 48 hours before surgery to
allow for decision making time.
Rationale:
There have been 30 successful claims in the UK between 1995 and 2009 related to TURP. The
average payment per surgical claim is £41,600. The commonest causes for litigation post-prostate
surgery are sexual dysfunction, incontinence and stricture.
Audit sample: 50 cases.
Data source: Retrospective data collection from patient Health Care Files
Results: Comparing July 2011 audit with August 2012 re-audit
Conclusions:
1) Improvement in practice
2) TURP patient sticker (introduced from 2011 audit recommendations) was used in 30 consents
3) 75% given information about TURP
4) 2 consents lost.
Recommendations:
1) Continue using the TURP patient sticker (with all the complications of the procedure TURP)
2) To make sure all consent forms are filed safely in the medical notes and eHR.
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
16
Case Study 2
Movement of Patients with Alert Organisms
Objectives:
Reduce the risk of cross infection for all patients in the Trust.
Alert Organism – What is it?
Alert Organisms include MRSA,
C.Diff and other antibiotic resistant
organisms. They are the cause of
outbreaks of infection on wards and
are monitored closely.
Rationale:
To establish if the movement of these patients (making sure that they are only moved when clinically
necessary) is causing a problem as perceived.
Standards: JPUH Guidelines
Audit sample: 139 patients identified from Infection Control data "Alert List" from December 2011
Data source: Retrospective data collection from iPM
Results: Comparing September 2010 audit with April 2012 re-audit
Conclusions: Results are very good; particularly considering pressure for beds within the Trust.
Recommendations: Infection Prevention Nurse Specialist will continue to monitor patients with alert
organisms and will continue to remind staff that they should not be moved inappropriately.
Case Study 3
Cataract surgery visual and refractive outcomes 2012
Objectives:
Audit visual and refractive outcomes after cataract surgery
Audit biometry accuracy
Audit complication rate
Audit patient satisfaction
Rationale:
High volume surgery and an indicator for revalidation
Audit sample: 250 patients identified from personal log over a 12 month period.
Data source: Personal logbook, optometrist feedback forms
Results: Comparing 2012 results with previous annual results.
Conclusions: Good results, exceed benchmarks. Poor return rate of feedback forms.
Recommendations:
• Ensure every patient receives a feedback form
• Stress the importance of attending optometrist and presenting form
• Write to all optometrists to reiterate importance of feedback
• Audit which optometrists return data
• Accurate departmental database for all results
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
17
Case Study 4
NHS Litigation Authority (NHSLA) Mandatory Audit of Paper Health Care Records 2012
Objectives: A high level audit to ascertain correct record keeping standards across the Trust
National Standards: Information Governance (IG) toolkit, NHSLA
Audit sample: 450 cases from 1st-30th September 2012
Data source: Patient Paper Health Records
Data collection: Undertaken by FY1/FY2 Doctors, Nurses and Clinic/Clinical areas Staff
Results: 2012 results based on overall assessment of notes and compared against 2008, 2009 and
2010 results where possible.
Overall Conclusions:
A positive audit that shows that the Trust is improving in most areas regarding the use of patient‟s
records. Also that these records reflect accurately the care and treatment for the patient whilst
maintaining clinical and IG standards and upholding patient choice
Noticeable areas in the audit where standards have dropped are:
Ensuring PID (Personal Identifiable Data) is present on every patient document/page e.g. patient
name on page scored 57%, down from 78%
Noting whether the discharge summary has been sent to GP‟s scored 76%, down from 96%
A&E documentation present in the patients file when admitted scored 88%, down from 98%
All entries (including alterations/additions) identify author by reference to Nursing Accountability
Record scored 86%, down from 90%
All other criteria either scored better or the same than the previous audit, with the overall trend
moving upwards
Recommendations:
Records training to become part of induction training
Records training to be compulsory for all staff, either as an addition to IG or an extra separate
session
Dissemination of audit results to IG Action Group and to key individuals/groups
Audit results to dovetail into CQC action plan
National Confidential Enquiries
NCEPOD - What is it?
National Confidential Enquiry into Patient Outcome and Death (NCEPOD) is an
independent charitable organisation that reviews medical and surgical clinical practice and
makes recommendations to improve the quality of the delivery of care for the benefit of
the public. They do this by undertaking confidential surveys and research covering many
different aspects of care and making recommendations for clinicians and management to
implement.
The Trust has a dedicated lead for NCEPOD who provides regular reports regarding the
Trust‟s progress with implementing the recommendations from the published reports. Self
assessments have been carried out using the NCEPOD tools and action plans are in
place to ensure implementation of the recommendations.
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
18
Title
Subarachnoid
Haemorrhage
(Please note this
study is still open and
the figures have not
been finalised)
Alcohol Related
Liver Disease
Bariatric Surgery
Cardiac Arrest
Procedures
Aim
To explore remediable factors in the
process of care of patients admitted
with aneurysmal subarachnoid
haemorrhage, looking both at patients
that underwent an interventional
procedure and those managed
conservatively.
To identify the remediable factors in
the quality of care provided to patients
treated for alcohol-related liver
disease and the degree to which its
mortality is amenable to health care
intervention.
To describe variability and identify
remediable factors in the process of
care (from referral to follow-up) for
patients undergoing bariatric surgery.
To describe variability and identify
remediable factors in the process of care
of adult patients who receive resuscitation
in hospital, including factors which may
affect the decision to initiate the
resuscitation attempt, the outcome and
the quality of care following the
resuscitation attempt, and antecedents in
the preceding 48 hours that may have
offered opportunities for intervention to
prevent cardiac arrest.
Relevant
to JPUH
Services?
Trust
participation
Percentage
of Cases
Submitted
Yes
Yes
5
(3 included,
2 excluded)
Yes
Yes
3
Yes
2
No
Yes
Participation in Clinical Research
The number of patients receiving NHS services provided or sub-contracted by the James
Paget University Hospitals NHS Foundation Trust that were recruited during that period
to participate in research approved by a research ethics committee was 1171 (the target
for 2012/13 was 500).
The Commissioning for Quality and Innovation (CQUIN) Framework
A proportion of the James Paget University Hospitals NHS Foundation Trust‟s income for
2012/13 was conditional upon achieving quality improvement and innovation goals
agreed between the James Paget University Hospitals NHS Foundation Trust and any
person or body they entered into a contract, agreement or arrangement with for the
provision of NHS services, through the Commissioning for Quality and Innovation
payment framework. Further details on the agreed goals for 2012/13 and for the
following 12 month period are available online at: http://www.monitornhsft.gov.uk/sites/all/modules/fckeditor/plugins/ktbrowser/openTKFile.php?id=3275
The amount of income in 2012/13 conditional upon achieving quality improvement and
innovation goals is: £3,141,553
The amount of income received for the associated payment in 2011/12 was: £2,583,243
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
19
The Care Quality Commission (CQC)
The James Paget University Hospitals NHS Foundation Trust is required to register with
the Care Quality Commission and its current registration status is registered to carry out
the following legally registered services:
Maternity and midwifery services
Termination of pregnancies
Family planning services
Treatment of disease, disorder or injury
Surgical procedures
Diagnostic and screening procedures
The Care Quality Commission has not taken enforcement action against the James
Paget University Hospitals NHS Foundation Trust during 2012/13.
The James Paget Hospitals NHS Foundation Trust has not participated in any special
reviews or investigations by the Care Quality Commission during the reporting period.
Quality of Data
Hospital Episode Statistics
The James Paget Hospitals NHS Foundation Trust submitted records during 2012/13 to
the Secondary Uses Service (SUS) for inclusion in the Hospital Episode Statistics which
are included in the latest published data. The percentage of records in the published
data:
 which included the patient's valid NHS Number was:
• 99.6% for admitted patient care;
• 99.8% for outpatient care; and
• 99.1% for accident and emergency care.
 which included the patient's valid General Practitioner Registration Code was:
• 100% for admitted patient care;
• 100% for outpatient care; and
• 100% for accident and emergency care.
Information Governance
Information Governance - What is it?
Information Governance (IG) is the way in which the NHS handles all information and in
particular the personal and sensitive information of patients and staff.
Following strict IG guidelines enables the Trust to ensure that personal information is dealt
with legally, securely, efficiently and effectively, in order to deliver the best possible care to
our patients.
The James Paget University Hospitals NHS Foundation Trust Information Governance
Assessment Annual Report overall score for 2012/13 was 72% and was graded GREEN
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
20
The table below shows this year‟s position against previous year‟s results.
Year
Overall Result
2011 Result
2012 Result
2013 Result
(IGT version 8)
(IGT version 9)
(IGT version 10)
68%
71%
72%
(Satisfactory)
(Satisfactory)
(Satisfactory)
(45 out of 45 answered)
(45 out of 45 answered)
(45 out of 45 answered)
The improvement in the Trust‟s percentage score shown above is as a result of an
improvement in the Trust‟s performance in Requirement 505 (Clinical Coding performance).
A very positive audit report increased performance in this Requirement from Level 2 to Level
3.
Version 11 of the Information Governance Toolkit (IGT) is expected to be released in June
2013 and no significant changes to Version 10 are anticipated at this time.
The James Paget University Hospitals NHS Foundation Trust will be taking the following
actions to improve data quality [in relation to Information Governance]:
An Improvement Plan for the 2013/14 IG Toolkit will be developed during May 2013,
looking to strengthen the evidence available to the Trust in support of Version 10. It is
anticipated that the Improvement Plan will need some minor enhancements once the
impact of the IG Toolkit Version 11 release is understood.
Payment by Results
Payment by Results - What is it?
Payment by Results (PbR) is the rules-based payment system in England under which
commissioners pay healthcare providers for each patient seen or treated, taking into
account the complexity of the patient‟s healthcare needs.
PbR currently covers the majority of acute healthcare in hospitals, with national tariffs for
admitted patient care, outpatient attendances, accident and emergency (A&E), and some
outpatient procedures.
The James Paget University Hospitals NHS Foundation Trust was subject to the
Payment by Results clinical coding audit during the reporting period by the Audit
Commission and the error rates reported in the latest published audit for that period for
diagnoses and treatment coding (clinical coding) were 8.2%.
The clinical coding results should not be extrapolated further than the actual sample
audited. The services reviewed within the sample were:
Ear, nose and throat
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
21
The James Paget University Hospitals NHS Foundation Trust will be taking the following
actions to improve data quality [in relation to Payment by Results]:



Improve the identification and coding of co morbidities and secondary codes.
Address the specific issues noted in the audit including:
Reminding coders of the correct coding of patients admitted for fitting of
ApneaGraph;
improving the extraction of information for coding; and
ensuring the information coded is for the correct admission.
Remind clinicians in A&E to fully record the time of the decision to admit to ensure
that activity is coded within the correct setting.
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
22
Part 3 Review of Quality 2012/13
This section details how we have done against the targets we set in our 2011/12 Quality
Account. Where relevant we have included what we said within the 2011/12 Quality Account
as an easy reference for the data included. It is set out in the same way as the summary on
page 3.
Where possible we have included historical performance and where available we have
included national benchmarks.
1
Patient Safety
(a)
To achieve and maintain compliance with all Care Quality Commission
(CQC) outcomes
Achieved
CQC - What is it?
They are the independent regulator of all health and social care services in England.
Their job is to make sure that care provided by hospitals, dentists, ambulances, care
homes and services in people‟s own homes and elsewhere meets national standards of
quality and safety.
The national standards cover all aspects of care, including:
treating people with dignity and respect
making sure food and drink meets people‟s needs
making sure that that the environment is clean and safe
managing and staffing services
They register care services that meet the standards, inspect them to check that they
continue to do so, and take action when they don‟t.
During the last financial year (2011/12), there were found to be insufficient arrangements in
place to demonstrate compliance with CQC outcomes. Over the past year a robust system
of assurance audits, checks and improvement actions have been delivered to achieve and
maintain compliance with all CQC outcomes.
During 2012/13 there were three unannounced Care Quality Commission (CQC) inspections
related to core Foundation Trust activities. At each of these inspections, the Trust was found
to be compliant with the outcomes reviewed. The Trust was found to be fully compliant with
all CQC outcomes in July 2012. A subsequent CQC inspection conducted in February 2013
reaffirmed that the Trust is fully compliant in all areas.
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
23
2
Clinical Outcomes and Effectiveness:
(a)
Achievement of the CQUIN scheme
Achieved
Goal No
1
2
3
4a
4b
4c
5a
6
7a
7b
8b
9
10
11
12
13
14
15
16
(b)
Description of Goal
1% System wide scheme
VTE
National Inpatient Satisfaction survey
NHS Safety Thermometer
Dementia Case finding
Dementia risk assessment
Dementia – Referral to specialist services
Patient satisfaction
Medicines reconciliation
A & E liaison with other organisations (sharing criminal data)
Alcohol screening
Maternity services
Frequent Attenders
Introduce sepsis care bundle across the Trust
Falls – reduction of harm
Reduce incidence of Grade 3 and 4 Pressure Ulcers
SCG - Breast Feeding
SCG - Renal Patient View
SCG - Renal Home dialysis
SCG - Dashboards
Forecast %
Achieved*1
96.6%
100.0%
50.0%
66.7%
0.0%
0.0%
0.0%
66.0%
100.0%
100.0%
67.0%
20.0%
66.7%
50.0%
100.0%
51.5%
100.0%
100.0%
100.0%
100.0%
Reduce hospital acquired pressure ulcers across the Trust
Partially Achieved
Introduction
What we said in our 2011/12 Quality Account:
This will be measured by comparing 2011/12 and 2012/13 occurrences per
thousand occupied bed days. The Trust will participate in the national safety
thermometer survey and the NHS Midlands and East Ambition to eliminate all
avoidable Grade 2, 3 and 4 pressure ulcers by December 2012.
1
Forecast is based on position to March Board of Directors
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
24
What is an „avoidable‟ pressure ulcer?
“Avoidable” means that the person receiving care developed a pressure ulcer and
the provider of care did not do one of the following: evaluate the person‟s clinical
condition and pressure ulcer risk factors; plan and implement interventions that are
consistent with the persons needs and goals, and recognised standards of
practice; monitor and evaluate the impact of the interventions; or revise the
interventions as appropriate.”
When is a pressure ulcer „unavoidable‟?
“Unavoidable” means that the person receiving care developed a pressure ulcer
even though the provider of the care had evaluated the person‟s clinical condition
and pressure ulcer risk factors; planned and implemented interventions that are
consistent with the person‟s needs and goals; and recognised standards of
practice; monitored and evaluated the impact of the interventions; and revised the
approaches as appropriate; or the individual person refused to adhere to
prevention strategies in spite of education of the consequences of nonadherence”.
During 2012/13, there were 41 grade 3 hospital acquired pressure ulcers – three of these
were classed as „unavoidable‟.
Grades 2, 3 and 4 Hospital Acquired Pressure Ulcers 2010/11 to 2012/13
NB: There were no Grade 4 hospital acquired pressure ulcers for the time periods above.
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
25
What we have done
1
Safety Thermometer
We use the Safety Thermometer (see „What is it?‟ on page 6) across the inpatient areas,
including maternity and paediatrics, of the Trust (corporately) to see, at a point in time, how
many harm incidents are occurring. This information is then used to help us understand
where further work is needed and to plan activities to make improvements. The Trust wide
picture is gained by all wards using the Safety Thermometer within their own areas (locally)
and then all of the information being centrally collected and analysed.
The aim of the Safety Thermometer is to support achievement of 95% harm free care in four
specific areas of care. In relation to pressure ulcers the Safety Thermometer data shows
that from April 2012 – March 2013 our incidence of pressure ulcer has decreased from
4.37% to 1.47%. There continues to be some variation in sustaining month on month
improvements which is also reflected in our internal monitoring.
Reducing actual incidents of hospital acquired pressure ulcers and achieving a reduction in
variation of improvements will be our priority for 2013/14.
2
The SSKIN Care Bundle
The SSKIN Care Bundle - What is it?
Care bundles are collections of interventions or actions. They are used to manage particular
situations or to reduce and prevent complications, for example to prevent a pressure ulcer.
When all the interventions are used together, safety and effectiveness is increased and the
patient‟s experience is improved. The SSKIN care bundle has been developed from an
evidence base that describes the interventions required to help prevent tissue damage and
pressure ulcer development
The acronym stands for:
Surface – make sure your patients have the right support
Skin inspection – early inspection means early detection show patients and carers what to look for.
Keep your patients moving
Incontinence/Moisture – your patients need to be clean and
dry
Nutrition and Hydration – help patients have the right diet and
plenty of fluids
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
26
3
The Pressure Ulcer Prevention Collaborative:
The Trust participated in a regional Pressure Ulcer Prevention Collaborative. The purpose of
the Collaborative was to support teams to use the Model for Improvement, see below, as a
specific way to support consistent and sustainable implementation of the SSKIN care
bundle. The Model for Improvement underpinned the programme, enabling teams to
connect an aim to an action and measurement to demonstrate their progress. Two wards
represented the Trust in the Collaborative between September and December 2012.
We have carried out audits on our use of the SSKIN bundle and they show that we are
improving. The audits also show where continued improvements may be required. The plan
is to now roll out the collaborative methodology/approach and spread the learning across all
wards.
The Model for Improvement - What is it?
4
NHS Midlands and East Ambition
The NHS Midlands and East Ambition - What is it?
One of NHS Midlands and East's five ambitions was to "Eliminate avoidable grade 2, 3 and 4
pressure ulcers by December 2012." Avoidable pressure ulcers are a key indicator of the
quality of nursing care. Preventing them happening will improve all care for vulnerable
patients.
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
27
What we said in our 2011/12 Quality Account:
„The Midlands and East Strategic Health Authority Ambition to reduce all avoidable hospital
acquired pressure ulcers by December 2012 has been embraced by the Trust which is
participating in data collection via the NHS Safety Thermometer.‟
What we are going to do next




The Safety Thermometer will be used in combination with other measurement tools to
inform our improvement actions.
The Trust remains committed to achieving the Ambition and will continue to strictly
monitor and work towards elimination in the forthcoming year by continuous review of the
application of the SSKIN bundle.
We expect the level of reporting of pressure ulcers will reach a plateau within this year
and this will give us a more reliable baseline for future measurement and monitoring.
There will be a detailed analysis of all grade 3 hospital-acquired pressure ulcers during
this year. Learning points identified from this will be used to guide next steps /
improvement actions
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
28
3
Care and Staff Experience:
(a)
To embed the recommendations from the Organisational Development
Review related to patient experience
Partially Achieved
Introduction
What we said in our 2011/12 Quality Account:
„In Your Shoes / In Our Shoes – Focus on patient and staff experience…..‟
„…..by involving staff and patients in telling us what our culture is like today;
designing a new high-performance, people-centred culture; and setting out an
organisational development (OD) plan to launch, embed and sustain that new
culture‟
From these sessions patients and carers stated they wanted the hospital and its
staff to consistently be:•
•
•
•
Courteous and respectful
Attentively kind and helpful
Responsive in our communication
Effective and professional
Timeline for Organisational Development Plan
September & November 2011: CQC inspections highlighted failings in
Essential Care Standards
December 2011: Trust-wide programme to involve patients and staff in
improving patient care established
January 2012: diagnostic findings
Need for an ambitious shared vision and clear goals with patient care at
its heart
Inconsistent understanding of Trust values – adherence to patientcentred values patchy
Need for fair and reasonable performance management systems to
develop those with potential and appropriately support/manage underperformance
Poor performance not challenged and improvements not celebrated
James Paget University Hospitals NHS Foundation Trust
Quality Account 2012/13
29
February 2012: 800 staff and 100 patients engaged in developing a patient
and staff experience vision and explicit standards of attitude, behaviour and
communication
March 2012: Organisational Development plan to remove barriers, build
enablers and sustain improvement approved by Board and submitted to PCT
November 2012: Programme restarted following appointment of Interim Chief
Executive, addressing the issues highlighted by the CQC and the new Patient
Flow Project
What we have done
Established a Behaviours Framework
The process for this was agreed within the Trust Organisational Development strategy in
March 2012. The action plan has included responsibility for behaviours at organisational,
team and individual level with aligned Human Resources and measurement processes.
The agreed process was set out to:
1
Establish shared expectations of Attitude, Behaviour and Communication
– Our values and behaviours:
2
Support leaders and managers to role model and manage the expected
behaviours
This work commenced in November 2012. Internal facilitators were trained and two hour
development sessions have been run for all 200 managers and clinical leaders within the
Trust. The sessions include: understanding what patients and carers expect from staff;
discussing the importance of role modelling these behaviours, providing a cascade feedback
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Quality Account 2012/13
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system for managers and clinical leaders to share the framework with staff. The programme
has provided managers access to Trust-wide tools to share behaviours with staff including:
Credit card-sized reminder – this is also given to all staff once the managers have cascaded
the initial training to them
Front
Back
In addition to this the behaviours are embedded in organisational processes such as:
“Know how you are doing” boards on each Ward
National patient surveys
Staff Surveys
Using culture surveys
There are also local and organisational action plans for both staff and patient experience that
are managed through formal committee mechanisms. See page 4 for the Trust‟s committee
structure.
At an individual level the emphasis on personal responsibility is embedded in the new
appraisal documentation that allows staff to undertake a self-assessment of their behaviours
and then to discuss this with their manager and agree an action plan if required.
What we are going to do next
To embed the behavioural framework:

Quarterly focus on each of the standards: awards, posters (using „champion‟ photos)
 Regular internal communications, team briefs, reporting patient experience
measures/improvements
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